Introduction by Croakey: Strong recommendations for improving Aboriginal and Torres Strait Islander peoples’ access to mental healthcare through Medicare, telehealth and the NDIS are made below.
Researchers call for increased access to culturally adapted therapies, improved follow-up for First Nations people with care plans, co-design of telehealth services for cultural safety, and efforts to fix “blind spots” in the NDIS.
Their recommendations come from detailed analyses of linked Medicare, Census and NDIS data covering the diverse population of Southeast Queensland, which also highlight the importance of addressing housing insecurity.
“These findings offer a valuable opportunity for governments, funders and service providers to reflect on where systems are working, and where they are falling short for First Nations communities,” they write.
The authors are Dr Xiaoyun Zhou and Dr Sandra Diminic, from the Queensland Centre for Mental Health Research and the School of Public Health at The University of Queensland, and Professor Roxanne Bainbridge, Deputy Director of the ARC Centre of Excellence for Indigenous Futures.
Xiaoyun Zhou, Sandra Diminic and Roxanne Bainbridge write:
As the Australian Government rolls out its $11.8 billion Strengthening Medicare reforms, focused on improving primary care access, mental health and equity, our new research reveals that these goals remain out of reach for many First Nations Australians with mental health needs.
Despite policy commitments to deliver person-centred, culturally responsive care, our linked data analyses across Medicare, telehealth, and the NDIS in Southeast Queensland show persistent and systemic gaps.
From over-reliance on general practitioners and underuse of psychologists, to long delays after mental health care plans and under-recognition of some mental health conditions for access to NDIS support, these findings signal urgent priorities for reform.
With Croakey readers engaged in shaping health policy and practice, this article offers timely insights into how system reforms can better respond to the needs and rights of First Nations people in Australia.
Key findings
Key findings include the underuse of therapy, gaps in continuity of care and barriers in NDIS access.
Across Medicare-subsidised mental health services, First Nations Australians had higher overall access rate (16.71 percent versus 11.81 percent) than non-Indigenous people but the type of care they received raised red flags.
They were more likely to rely on GPs for mental health support and less likely to access psychologists or receive psychotherapy sessions. Even when care plans were developed, many experienced long delays in accessing follow-up support.
Alarmingly, 60 percent of First Nations Australians with a mental health care plan had no follow-up service at all in 2021, compared with 44 percent of non-Indigenous people.
Telehealth expanded access for some, particularly in remote areas, but did not close the service gap.
Overall, First Nations Australians accessed fewer telehealth services than non-Indigenous Australians, and when they did, they were more likely to use phone calls rather than video, which limits therapeutic depth. Men and older adults (70+) were especially underrepresented in telehealth uptake.
NDIS analysis showed some positive signs. First Nations Australians with identified mental health needs were slightly more likely to access NDIS psychosocial supports than their non-Indigenous counterparts and received comparable budgets.
However, these supports skewed toward those with psychotic disorders, while those with mood, anxiety or trauma-related disorders appeared underrepresented relative to non-Indigenous participants.
Unstable housing also emerged as a major access barrier, with those moving multiple times a year far less likely to access or continue with NDIS services.
Critically, 88 percent of NDIS plan utilisation data were missing from the dataset, which severely limited our ability to evaluate whether participants received the support they needed, how funds were used or whether equity targets are being met, given the availability of affordable and culturally responsive NDIS supports remains a known barrier for many First Nations Australians in accessing and fully utilising their plan budgets.
This data gap raises urgent concerns about transparency, accountability and the capacity of current monitoring systems to guide meaningful reform.
Policy priorities
Policy reforms must move beyond access and focus on appropriateness, continuity and cultural responsiveness.
A recurring pattern across all systems is that access alone does not guarantee equitable or effective support.
What is needed now is investment in culturally safe, First Nations-led models that strengthen the capacity of all kinds of services, including both mainstream services and delivered through Aboriginal Community Controlled Health Organisations (ACCHOs), to address structural and cultural barriers.
Recommendations are made below.
1. Boost access to culturally adapted therapies
Medicare subsidies often favour short GP consultations over longer therapy sessions, and the high gap fees for psychological care remain a major barrier for many First Nations Australians.
Clinicians are also not adequately supported or incentivised under Medicare’s fee-for-service model to provide holistic, patient-centred care – such as coordinating with other providers, supporting people with complex needs, or helping them navigate fragmented systems. The system is transactional, geared towards acute care rather than the chronic, interwoven health and social issues many people face.
Rebalancing rebates and expanding access to First Nations-specific psychology services is part of the solution.
But we also need to challenge assumptions—structured psychotherapies like CBT may not align with all First Nations worldviews, and cultural adaptations are often lacking.
Expanding community-led healing programs and embedding First Nations mental health workers into care teams could shift the dynamic.
Importantly, these changes rely on reforming how services are funded. Activity-based funding does not lend itself to culturally responsive or coordinated care.
We need value-based and outcomes-based models that prioritise relationships, continuity, and community-driven approaches.
2. Close the follow-up gap
More than half of First Nations people with care plans recorded no follow-up treatment.
Transport barriers, inflexible hours, long waiting lists, lack of workforce, gap fees, racism, cultural mismatches between medical professionals and First Nations clients all contribute.
Community-based mental health hubs, flexible service hours and stronger care coordination (including funding First Nations liaison roles) could improve engagement.
3. Co-design telehealth for cultural safety
Telehealth has promise but is not a silver bullet. Phone-based consultations dominate, partly because of infrastructure gaps, digital literacy barriers and preferences of First Nations community members and health providers.
Investing in community digital access, promoting video consultations and co-designing culturally relevant telehealth models with First Nations communities are essential steps.
4. Fix blind spots in the NDIS
The overrepresentation of psychotic disorders among First Nations NDIS participants suggests under-recognition of other mental health conditions requiring support.
Funding should prioritise improving assessors’ understanding of mental health and psychosocial disability in First Nations contexts.
Targeted, culturally appropriate resources are also needed to support community navigation of the complex NDIS access process.
Embedding NDIS access navigators within ACCHOs can further enhance engagement and support.
Additionally, improved data collection on Indigenous identity and service use is essential for monitoring equity, as current datasets misidentify around 30 percent of First Nations participants.
Evidence and equity
These findings draw from detailed analyses of linked Medicare, Census and NDIS data covering the diverse population of Southeast Queensland, which includes urban and regional communities.
The study explored Medicare-subsidised mental health items, and mental health services delivered via telehealth and NDIS access and utilisation among people with self-reported or Medicare-recorded mental health needs.
By comparing First Nations and non-Indigenous peoples’ experiences across these systems, we identified patterns in who accesses services, what type of care is received and how these services align, or fail to align, with people’s needs.
Equity does not mean providing the same care for everyone. Rather, it means recognising different needs, histories and preferences in the care continuum.
Our findings point to a health system that still expects First Nations people to navigate services that were not designed for them. As a result, care is often fragmented, inappropriate or culturally irresponsive.
We know what works: Indigenous leadership, community-controlled services, localised models of care and investment in holistic mental health approaches that recognise the social determinants of health and wellbeing.
These findings offer a valuable opportunity for governments, funders and service providers to reflect on where systems are working, and where they are falling short for First Nations communities.
With the data now pointing clearly to priority areas for reform, the next step is to ensure that we listen, learn and work in genuine partnership to deliver meaningful change.
Acknowledgements and governance
Dr Xiaoyun Zhou and Dr Sandra Diminic are non-Indigenous mental health researchers based in Meanjin (Brisbane). Professor Roxanne Bainbridge is an Aboriginal researcher from the Gunggari and Kunja Nations. The studies discussed in this article were conducted in close collaboration with the Institute for Urban Indigenous Health (IUIH) and The University of Queensland Centre of Excellence for Indigenous Futures.
We acknowledge and thank the members of our project steering committee, as well as the Indigenous health providers and community members who generously contributed their time and insights to inform the study’s design, conduct and interpretation. Their guidance was essential to ensure the research remained grounded in the lived realities, priorities and cultural contexts of First Nations people. This work is a reflection of that partnership, and we remain committed to upholding Indigenous data sovereignty and leadership in all aspects of our research.
Related articles published this week
Five priorities for the Albanese Government to transform Australia’s mental health system
Calling for national leadership to address workforce shortages in community mental health services
See Croakey’s archive of articles on mental health
