National Mental Health Commission
PO Box R1463,
Sydney NSW 2000
Re: Review of Mental Health Services and Programmes
Thank you for the opportunity to comment on the Australian Government’s review of funded mental health programmes and services.
Since the introduction of effective medical treatment in the 1950’s, leading to deinstitutionalisation of people with severe and enduring mental illness and the growth of community-based treatment settings and services, the situation of people with mental illness has improved. People who experience illnesses such as schizophrenia are more likely to have their human rights recognised, understanding that the use of seclusion and restraint (both physical and chemical) is still far too prevalent. People are now more likely to seek treatment or help. However, people with mental illness still experience a significantly reduced quality of life including reduced educational outcomes, high unemployment, high incidence of chronic disease, social isolation and vastly reduced life expectancy.
Many of these adverse outcomes are not attributable to the symptoms of mental illness, but rather to the impact of the experience of mental illness. The episodic nature of many mental illnesses results in interruption to education, employment, relationships and engagement with the community. Families bear much of the burden, resulting in the social and economic impacts of mental illness being shared more broadly. Community stigma and the resulting discrimination too often deny people in recovery the opportunities to become full and active participants in the community again.
Clinical interventions (principally medications) have improved over time in eliminating or reducing symptoms, but significant challenges remain, medications still have burdensome adverse side- effects, including weight gain, reduced motivation, and increased incidence of diabetes. There is a vital need for stronger links between psychiatry and primary health to manage adverse physical health outcomes.
The development of community support and recovery services over 30 years, particularly in Victoria, has further contributed to better outcomes for people with mental illness. People with schizophrenia are now gaining competitive employment where once this was considered unlikely. But the possibility of these outcomes is not universal and the accessibility, quality and focus of mental health services across the country vary widely.
We believe that there is a significant opportunity for the federal government to build on the gains made in mental health services. Successive National Mental Health Plans and the development of national quality standards have contributed positively to improved quality of services, as have commonwealth investments in mental health, including Personal Helpers and Mentors, Support for Day to Day Living and Access to Allied Psychological Services (ATAPS) initiatives.
However mental health as a proportion of burden of disease remains chronically under-resourced. Cohealth believes that in a health environment facing the pressure of an ageing population and an increased prevalence of chronic illness, there is a real risk the under-investment in mental health services will continue or worsen. It is in this context that we welcome the opportunity to contribute to considerations of future investment in mental health services.
Future investment in mental health services in Australia needs to focus on consistency of quality (founded on human rights), accessibility and responsiveness to community diversity, and continuity of care. Clinical treatments need to be complemented by a robust community support service system that supports people to regain their community tenure to once again become contributing and valued members of the community. This is both most effective and most cost-effective when provided early in the course of a severe mental illness. A robust community support service system offers the greatest chance of stopping the ‘revolving door syndrome’ that results both in over-demand for acute services and poorer outcomes for consumers.
Among the broad range of issues around the building of an effective, efficient and sustainable mental health system across Australia, cohealth submits the following as key issues for consideration.
Responsiveness to diversity
Mental illness does not occur in a vacuum. It is the result of many factors which occur in people’s environment and experience of life. This review of mental health services and programmes should provide a response that allows sufficient flexibility to respond to different communities in different ways. Theoretical constructs of mental illness differ widely among ethnic and cultural communities. For example, people from the Horn of Africa have no words in their native languages, for instance, that are equivalent to ‘mental illness’ or ‘schizophrenia’. A well-designed service system needs the flexibility to build effective interventions that respect cultural diversity.
Responsiveness to disadvantage: Social determinants of health
As with other illnesses and conditions that lead to poor health, the burden of mental health disproportionately impacts on communities that also experience other life inhibiting factors such as poverty and homelessness (in which access to services is disproportionately low, and engagement with ongoing service is exceptionally difficult) and among those communities of identity experiencing marginalisation and discrimination based on race and ethnicity, Aboriginality, sexuality, gender diversity and chronic substance use. There are clearly communities of place that experience disproportionate levels of mental illness with recent analysis in rural and regional Australia relevant.
In Melbourne the demand for services in the growth corridors such as Melton, Wyndham and Hume appears to be significantly greater than forecast based on population growth alone. The experience of housing stress seems to be running alongside higher rates of family violence and increasing levels of alcohol and other drug use. Health outcomes are poorer due to a lack of access to the health system while informal supports networks are under developed.
Mental health services need to be closely linked with the broad range of health and human services, including primary health, housing, education and employment, and family services. This is particularly important given that people with mental illness experience poorer physical health outcomes and, as a population, carry a greater burden of disease from chronic diseases. This makes linkages with community based primary health care services and systems all the more vital for people experiencing mental illness. Cohealth believes there is a coordination and facilitation role for mental health services to undertake.
Building the future: the voice of consumers and service co-design
The improvements in treatments for mental illnesses in the last sixty years have given rise to a vocal and robust world-wide mental health consumer movement. The focus of the consumer movement has been advocacy for human rights for people who experience severe and enduring mental illness. In recent years, this advocacy has begun to positively contribute to the design, monitoring and evaluation of mental health services. Cohealth‘s three founding agencies have benefitted from the significant input of consumers in re-designing services to achieve better consumer outcomes. Cohealth recommends a co-design model for the shaping of future mental health service and program options.
Co-design involves service users and health workers (across the relevant professional practice areas) coming together to understand how best an intervention, service or program can meet the needs of the population for whom the service is intended. Co-design encourages innovation to remove barriers to initial and ongoing access and optimise the experience of service users and their families /carers/communities of support. Co-design shares information and stakeholder perspectives to improve understanding of the experiences of different stakeholders in services (service user, health worker, support worker, carer, family) so that changes can be made where poor experiences of services with detrimental impact occur, while experiences that promote engagement and better outcomes are supported and embedded.
Cohealth recommends investment in the development of a consumer workforce within mental health that both builds co-design capacity and creates employment and career opportunities to people who are ‘experts by experience’.
Investment to meet demand and improve outcomes
The federal government plays a vital role in the funding and provision of mental health services. Its leadership on mental health has improved community understanding with the outcomes including higher levels of access to funded mental health services (albeit from a low base).
The mental health service system is experiencing growth in demand without a commensurate increase in resources. This creates systemic risk: waiting lists and other access barriers result in individuals experiencing suboptimal health and life outcomes and consequently making greater demands on the health system.
Cohealth recommends that the federal government grow the resources that are available to support mental health services and programmes nationally.
Any reduction in effort by the federal government will result in greater pressure on the service system and lead to poorer health outcomes at the individual and community level and increased demand on the health system.
There are a range of services and supports for people experiencing mental illness that are funded at both Commonwealth and State /Territory level. There would be benefit in simplifying administrative processes associated with the variety of programmes while ensuring that service provider governance and quality processes protect and enhance the experience and outcomes of service users.
Cohealth recommends that the Standing Council on Health appoint a working party with membership from across jurisdictions and the service delivery sector to improve the alignment of reporting and governance requirements for funding, with the aim of reducing the proportion of funding allocated to mental health service delivery that is taken up in governance, compliance and administrative processes.
Should there be duplication between State and Commonwealth funded programmes, it is vital that both tiers of Government negotiate a suitable outcome that sees no reduction in effort across the system. The ‘federation dance’ must stop. This is an all too familiar jurisdictional interplay that occurs when one tier of Government increases effort in an area of co-responsibility, such as mental health, while the other tier of Government reallocates resources or withdraws funding completely as a result. A slight improvement in the budget bottom line of one of the Governments results in detrimental health and life outcomes of those experiencing mental illness. Cohealth recommends that the Council of Australian Governments commit to an increase in resources available to respond to a growing burden of mental illness and that this commitment be based on growth in effort across all jurisdictions.
Consistent with the rest of Australia’s health system, the lack of coherent approach to funding responsibility results in ad hoc investment decisions being made which do not result in the best health outcomes. This results in an increased reliance on services and interventions at the acute end of the service system (also the most costly to support) while early intervention supports in the community become marginalised in the funding equation. Cohealth recommends the prioritisation of investment in community based supports that target interventions earlier in the experience of mental illness.
Local and linked service system
It is clear that delivering services as close as possible to where people live and work in as normal an environment as their life experience allows, will produce better health and life outcomes than waiting for an acute episode which requires intense acute interventions occurring away from family and community support. This is as true in mental health as it is in managing diabetes.
Delivering support in the community earlier in the experience of mental illness improves capacity to link people with other systems such as education, training, employment and housing as well as programs that improve social connection, improve resilience to mental illness or improve management of chronic health conditions. Current funding parameters do not encourage such linkages to the greatest extent possible.
Cohealth recommends that mental health service and program funding provide an incentive for consumers and service agencies to achieve better outcomes across the education, training, employment and housing systems.
Evidence-based and accountable services
Cohealth recommends that mental health services funded by the Australian Government be required to show through evaluation the efficacy of services and interventions as well as the sustainability of the service model used to achieve improved health outcomes.
Without these three elements embedded there is a risk that support for funding mental health programmes will diminish, thus jeopardising ongoing delivery of vital programmes and supports.
Cohealth welcomes the movement towards outcomes-focussed and client-directed funding models. We take seriously our effective and efficient use of public funding. Too often, systems accountability fails to take account of service user experience and long-term outcomes. Client-directed funding models are particularly vital in mental health, given the profound personal impacts that mental illnesses have on those who experience them.
Efficacy of services and interventions need to be aligned to evidence about the course of illness, For example, far from being a degenerative illness, the prognosis for schizophrenia improves over time. Typical onset is mid to late teens, but for most consumers symptoms abate in the mid to late twenties. Our service system needs to be designed to minimise the impact during this time, particularly on education attainment, beginning employment, supporting families, and encouraging age-appropriate development.
The federal government needs to contribute (with service providers) to the further development of evidence through a commitment to research in the effectiveness of community-based interventions to ensure the efficacy of services to achieve client outcomes and to demonstrate good return on investment. The lack of evidence underpinning investment in services post-institutionalisation contributes to both a fragmented service system and significant under-funding.
Early intervention and the NDIS
The National Disability Insurance Scheme (NDIS) is a transformational reform in the delivery of services in the health and social sector. The transition to person-controlled care with individual funding packages will move control of services from providers to consumers. A proportion of mental health consumers will in future be supported by the NDIS.
The move to an insurance-based service model for people who experience significant (psychiatric) disability as a result of mental illness is both necessary and welcome. But cohealth believes there is a significant risk that the consequent cost-shifting may result in a lack of available interventions early in the course of illness that prevents the development of disability. This would be detrimental both to consumer outcomes and system demands. It makes no sense to provide services to people only when they become permanently disabled. Though outside the scope of this review the approach to support of people experiencing mental illness through the NDIS will be a key consideration as to the future funding of mental health programs and services. Important within this will be access to services and supports by those who experience episodic mental illness as compared to chronic or permanent mental illness.
An example of an early intervention program is the Personal Helpers and Mentors service (PHaMs). PHaMs does not require the service user to have a formal psychiatric diagnosis, rather that their experience is such that an emerging mental health condition can be addressed through support in the community. The experience of workers in this program is that service users are less likely to experience a more enduring psychiatric disability or an increase in acuity. In the long term this is a far more cost effective approach as well as producing better health and life outcomes for service users.
PHaMs has also improved responsiveness to different cohorts including people from culturally and linguistically diverse programs, refugee and asylum seeker backgrounds and older people. These are groups that have lower levels of health service access than the broader population and thus the support provided through PHaMs can cross areas such as support in managing mental health issues, access to sustainable housing, engagement with education, training and employment and management of co-occurring health conditions. These interventions across the service spectrum can improve resilience to the future risk of mental illness.
An example of an innovative service response has been delivered by the Barkly Arts Centre, a cohealth service which engages with marginalised individuals and groups through community cultural engagement. The Benchmark Program is a unique program of cultural outreach to a community of young men from pan African communities, predominantly South Sudanese. Funded by the Department of Health’s Support for Day to Day Living in the Community, the program engages a large number of young men who have complex needs due to troubled histories as child soldiers and victims of war. Many of them have acquired brain injuries from alcohol abuse as well as multiple mental and physical health problems. Many are homeless or in insecure housing while others are in and out of the justice system. Barkly Arts Centre provides cultural outreach to this group in the form of a mobile music program. This program has allowed engagement with a service system unknown to participants previously and has provided opportunities for access and referrals to services and supports across the service system.
In summary the recommendations from cohealth to the National Mental Health Commission in undertaking this review are:
- cohealth recommends a co-design model for the shaping of future mental health service and program options.
- cohealth recommends investment in the development of a consumer workforce within mental health that both builds co-design capacity and creates employment and career opportunities to people who are ‘experts by experience’.
- cohealth recommends that the Australian Government grow the resources that are available to support mental health services and programmes nationally.
- cohealth recommends that the Standing Council on Health appoint a working party with membership from across jurisdictions and the service delivery sector to improve the alignment of reporting and governance requirements for funding, with the aim of reducing the proportion of funding allocated to mental health service delivery that is taken up in governance, quality and administrative processes.
- cohealth recommends that the Council of Australian Governments commit to an increase in resources available to respond to a growing burden of mental illness and that this commitment be based on growth in effort across all jurisdictions.
- cohealth recommends the prioritisation of investment in community based supports that target interventions earlier in the experience of mental illness.
- cohealth recommends that mental health service and program funding provide an incentive for consumers and service agencies to achieve better outcomes across the education, training, employment and housing systems.
- cohealth recommends that mental health services funded by the Australian Government should be required to show through evaluation the efficacy of services and interventions as well as the sustainability of the service model used to achieve improved health outcomes.
- cohealth recommends that consumer controlled care through individual funding packages be implemented across the health and community support systems, starting with funded mental health services and programmes.
I would be pleased to discuss this submission further with representatives of the Commission and provide further details in support of our recommendations.