Landmark mental health report urges reform. But we need more than Band-Aids

*** This post was updated on 20 November to include reaction from cohealth. ***

Nicole MacKee writes:

Two critical issues hit the headlines on Monday this week. The first was the long-awaited release of the Productivity Commission’s Mental Health Inquiry Report.

The three-volume final report, which was delivered to the Federal Government on 30 June, seeks to set Australia’s mental health system on a “path for sustainable, generational reform” and describes its vision for a patient-centred system.

The second issue was the announcement that the Federal Government had agreed to $1.2 billion settlement of the Robodebt case, in which hundreds of thousands of Australians were called on to pay unlawful welfare debts. Reports of suicide have been linked to the scheme.

While the timing of these announcements was coincidental, it illustrates a tension between efforts to improve Australia’s mental health system and actions that undermine a mentally healthy society.

On the one hand, the Productivity Commission’s report seeks to address key barriers to providing mental healthcare, and urges a firm commitment to systemic reform to provide “person-centred care”; on the other, the Robodebt controversy is an example of how governments’ actions, especially in non-health portfolios, can undermine the community’s mental health.

And while the mental health report has a strong emphasis on the importance of the social and emotional wellbeing of children, Australia’s attorneys-general this year voted for the age of criminal responsibility to remain at 10.

The decision was despite a 2019 United Nations Committee on the Rights of the Child recommendation of 14 years as the minimum age of criminal responsibility.

Also, research from the Australian National University, reported in The Guardian this week, has also estimated that an additional 330,000 people will sink below the poverty line when the Federal Government cuts the coronavirus supplement from 1 January next year.

The Productivity Commission’s mental health report was also released just days after the CSIRO and Bureau of Meteorology State of the Climate 2020 report painted a dire picture of Australia’s climate future.

Report rundown

“Australia’s current mental health system is not comprehensive and fails to provide the treatment and support that people who need it legitimately expect,” the Productivity Commission report stated.

The report said Australia’s system of community supports was “ad hoc”, with services starting and stopping with little regard to people’s needs.

“Our recommendations aim to establish a comprehensive community support system that operates seamlessly and in balance with the clinical care system, based on consumer and carer input and local requirements.”

The Productivity Commission has highlighted a range of priority reforms falling under five categories:

• Prevention and early help: early in life and early in illness. The Commission reported that the mental health of children and families should be a priority, starting with the mental health of new parents. It also called for the empowerment of Indigenous communities to prevent suicide attempts, follow-up care for people after suicide attempts, and a national stigma reduction strategy.
• Improving people’s experience with mental healthcare by creating a person-centred mental health system. This included getting people the right services at the right time and a focus on care continuity and co-ordination.
• Improving people’s experiences with services beyond the health system. The report called for a commitment to not discharge from care into homelessness and to better support people with mental illness to recover and live well in the community.
• Equip workplaces to be mentally healthy.
• Instil incentives and accountability for improved outcomes. Among a range of measures, the report called for consumer and care participation and advocacy in all aspects of the mental health system.

The report said a $2.4 billion investment in mental health system would produce significant benefits.

“These are mainly improvements in people’s quality of life — valued at up to $18 billion annually. There would be an additional annual benefit of up to $1.3 billion due to increased economic participation,” the report said.

“About 90% of the benefits — about $17 billion — could be achieved by adopting identified priority reforms, requiring
expenditure of up to $2.4 billion and generating savings of up to $1.2 billion per year.”

On the same day the report was released, Federal Health Minister Greg Hunt announced an investment of $133.5 million to support child, youth and perinatal mental health programs.

The package includes funding to extend the Be You school-based mental health program (delivered by Beyond Blue in partnership with headspace and Early Childhood Australia), additional funding for Emerging Minds to continue the National Workforce Centre for Child Mental Health, and funding to continue the Early Psychosis Youth Services (EPYS) program at 14 different headspace centres.

Gaps and barriers

A host of gaps and barriers were identified in Australia’s mental health system that lead to poor outcomes for people.

Importantly, the report recognised a disproportionate focus on clinical services – “overlooking other determinants of, and contributors to, mental health, including the important role played by family, kinship groups and carers, and providers of social support services, in facilitating a person’s functional recovery within their community”.

Other gaps and barriers included:

• A narrow view of people seeking treatment and support;
• Under investment in prevention and early intervention;
• Stigma and discrimination;
• Dysfunctional approaches to the funding of services and supports; and
• A lack of clarity across the tiers of government about roles, responsibilities and funding.

The report recommends reforms to address these gaps and barriers, and seeks to shape a person-centred, but flexible, mental health system.

“Reforms are extensive, comprising a mix of large-scale institutional changes, cultural changes and small but important adjustments to existing supports.”

The report has an emphasis on improving accountability and evaluation: “Rigorous evaluations of programs and policies in the mental health system are very important — and very rare. Evaluation should be embedded into program design.”

It says the Better Access program should, as a matter of priority, be rigorously evaluated to ensure that it is delivering cost-effective benefits for those who need it.

The report also acknowledges its limits:

Broader issues of health and social services reform lie beyond the scope of this Inquiry — although some of these issues have been the subject of previous Productivity Commission work (such as the Reforms to Human Services and Shifting the Dial reports). And we do not and cannot make recommendations that would eliminate mental ill-health.

There are a range of risk factors, such as those arising from deeply entrenched social, economic and environmental challenges, which lie beyond the scope of this Inquiry.

“While our recommendations would deliver a mental health system that is ready for the next major recession, pandemic, climate-change crisis or other shock to our community, we do not purport in this Inquiry to eliminate the risk of these and other social and environmental challenges.”

In terms of social determinants of health, the report does, however, make some key observations and recommendations.

Homelessness

The report calls for people with mental illness not to be discharged from hospitals, correctional facilities, and institutional care into situations of homelessness.

Some 16 percent of people with mental illness lived in unsuitable accommodation, the report found.

“Suitable housing — that is secure, affordable, of reasonable quality and of enduring tenure — is a particularly important factor in preventing mental ill-health and a first step in promoting long-term recovery for people experiencing mental illness,” it stated.

They also found that around 30 percent of admitted patients in psychiatric wards (about 2,000 people) could be discharged if appropriate housing and community services were available.

Justice system reforms

“Among those who formally enter the justice system, people with mental illness are over-represented at every stage,” the report said.

About half of police detainees (about 43 percent of men and 55 percent of women) were reported to have previously diagnosed mental disorder, while about 40 percent of those entering prison had been told they had a mental health disorder (including substance abuse).

“People with mental illness who are at high risk of interaction with the justice system should be identified and provided with mental health support that facilitates their inclusion in the local community and reduces their risks of offending. Some States and Territories have programs in this area already, and they should be endorsed more broadly,” the report said, citing the NSW Youth on Track program as an example.

Workplace mental health

The report emphasised the strong links between employment and mental health.

“Being employed can improve mental health and mentally healthy workplaces are important to maintain the good mental health of those who work there,” the report stated.

But, the report added, workplace hazards, such as bullying, were increasingly identified as contributors to psychological injuries.

“Workplace mental health and productivity would be improved by making psychological health and safety as important as physical health and safety in practice,” the report said. “The same risk management approach that applies to physical health and safety (an approach familiar to employers and employees) should be applied, as a priority, to psychological health and safety.”

The report recommended that workplace compensation schemes be amended to fund clinical treatment for all mental health related workers compensation claims.

Aboriginal and Torres Strait Islander mental health

Almost one in three Aboriginal and Torres Strait Islander people are in “high or very high psychological distress” (31%), the report found, compared with 14% of non-Indigenous Australians.

Also, suicide rates of Aboriginal and Torres Strait Islander people are more than double that of other Australians.

“Given the cultural diversity within Australia, the training of all clinicians should include measures that instil an understanding of how people’s cultural background affects the way they describe their mental health and their compliance with treatment options. This, and more, should be done for the mental healthcare of Aboriginal and Torres Strait Islander people,” the report said.

The report called for Indigenous-controlled organisations to be the preferred provider of care after a suicide attempt.

“For Aboriginal and Torres Strait Islander people, suicide attempt aftercare and other suicide prevention activity should, as a priority, have Indigenous-controlled organisations as the preferred providers, to increase the likelihood that program provision is sensitive to the experiences, culture and specific social issues faced within particular communities,” the report recommended.

“Stronger connection of individuals with their culture and control over services have reduced suicide risk and improved social and emotional wellbeing in some communities.”

Suicide prevention

In Australia, almost eight lives are lost to suicide every day, amounting to more than 3,000 deaths each year. And, the report said, for every death by suicide, hospital records showed there were as many as 30 attempts of suicide.

While only a small proportion of people with mental illness self-harm or have suicidal thoughts, two-thirds of people who died by suicide had a reported mental illness, the report said.

“However, 15-25% of people who attempt suicide will re-attempt, with the risk being significantly higher during the first three months following discharge from hospital after an attempt,” the report stated.

“Half of those discharged from hospital after a suicide attempt do not attend follow-up treatment and the responsibility of services and accountability for follow-up is unclear and inconsistent.”

The report found that adequate aftercare could reduce the number of people in hospital emergency departments, having attempted suicide, by about 20 percent and all suicide deaths.

“This is equivalent to preventing 35 people per year from dying by suicide, and a further 6,100 people per year from attempting suicide that results in some level of incapacity for them.”

The report also pointed to a range of suicide prevention trials underway across Australia. They noted that it was important that these trials reflect the needs of local communities.

Mental health stigma

“Some cultural and societal influences, such as stigma toward mental illness, exacerbate the cost of mental ill-health. They contribute to a reluctance for people to seek help (particularly in some cultural groups and in smaller communities where it is difficult to receive care without others becoming aware of this), alter the types of help people seek and the symptoms they experience, delay diagnosis, compromise adherence to treatment, and reduce the availability of social supports to both the consumer and their family and carer,” the report said.

It recommended that a national long-term stigma reduction strategy be implemented as a matter of priority.

• Also see this detailed Twitter thread by Croakey’s Dr Melissa Sweet.

Reaction

The Allied Health Professions Australia (AHPA) commended the Commission for recognising the need to expand access to psychological care.

However, the AHPA said in a media release, the focus of the Commission’s final report remained too narrow and neglected the potential of the allied health sector to make a significant contribution to the community’s mental health and wellbeing.

“Increased access to psychologists through videoconferencing, smaller groups, inclusion of family and carers in consultations and greater consumer choice with referrals is important and welcome”, said Claire Hewat, CEO of the AHPA. “However, opportunities to make a real difference by capitalising on the expertise of the broader allied health workforce have been missed.”

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The Australian Association of Social Workers National President Vittorio Cintio welcomed the report and its outline of a person-centred system.

“The Commission’s report focuses on a vision of preventing ill health, intervening early and delivering the full spectrum of clinical services and community supports that people need to recover and lead healthy, fulfilling lives,” Cintio said. “This means that supports and services need to be available whenever and wherever people need them. They need to be easily accessible, and culturally appropriate.”

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The Royal Australian College of General Practitioners (RACGP) “cautiously” welcomed the report’s proposals to improve mental healthcare after years of underfunding.

The Productivity Commission’s Mental Health Inquiry Report calls for a $2.6 billion overhaul of the mental healthcare system.

In a media release, acting RACGP President Associate Professor Ayman Shenouda cautiously welcomed the report.

“The RACGP welcomes the report’s aspirations to improve mental healthcare systems and improve funding, for what is a historically underfunded but critical area for the health of our nation,” Shenouda said.

“The report validates the unique role GPs play in mental healthcare, recognising the need for a whole-of-person approach to care, addressing mental and physical health in a holistic way, which is what a GP does.”

Shenouda said funding reforms must address the underfunding of mental health care in general practice.

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The Royal Australian and New Zealand College of Psychiatrists (RANZCP) also welcomed the report noting that it had come “not a moment too soon”.

RANZCP President Associate Professor John Allan said the report provided a strong starting point from which the country, governments and communities could work toward a strong, efficient and effective mental health system.

‘The time for change is upon us,” Allan said in a media release. “With our mental health system under more strain than ever, and facing a post-COVID pandemic surge, we have reached a crucial turning point.

‘Investment in mental health needs to be properly considered and made, as it is clear that the benefits will far outweigh the cost to invest.”

The RANZCP welcomed the call to make permanent all Medicare Benefits Schedule (MBS) items that were introduced during the COVID-19 pandemic.

‘The permanent continuation of telehealth, as an addition to face-to-face consultations beyond COVID-19, will provide a significant opportunity to enrich the future of Australia’s mental health service system, however we are concerned regarding the proposed 12 consultations per year limit as it will affect patient care.”

Allan also welcomed recommendations to reduce the stigma surrounding mental health.

The RANZCP was disappointed to note, however, that some key areas of mental health had been omitted, such as the mental health and wellbeing of older Australians.

‘It is disappointing … to see that there is a lack of recommendations relating specifically to the mental health of older Australians within the report.’

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Victorian not-for-profit community health service, cohealth, welcomed the final report from the Productivity Commission’s Inquiry into Mental Health, but says the report falls short in addressing many of the structural drivers of mental health such as housing, racism, and poverty.

cohealth said it was disappointed that the report explicitly excluded recommendations to address the fundamental causes of poor mental health — poverty, racism, inequality, unemployment.

‘The Federal Government controls a number of major social and economic levers which can impact people’s mental health,’ said Ms Nicole Bartholomeusz, Chief Executive, cohealth.

‘They can choose to reduce poverty by raising Jobseeker payments, increase social and affordable housing so that people aren’t living in unsafe accommodation or homelessness, improve social inclusion by investing in anti-racism programs and acknowledge the devastating impact that climate change has on people’s mental health, especially that of young people,’ Bartholomeusz said.

‘We now await the report of the Victorian Royal Commission into mental health to see how the Commonwealth and state reforms can be brought together to benefit our community now and into the future.’

Infographics from the report