Introduction by Croakey: Just over four years after a Royal Commission into Victoria’s Mental Health System tabled its final report and recommendations, a recent inquiry has highlighted slow and inadequate progress on recommended reforms.
Below, Simon Katterl (he/him), a mental health consultant and advocate with lived experience of mental health issues, takes a deep dive into the lessons that can be learnt from this state of affairs.
These include the importance of ensuring representation for consumers and First Nations peoples in such inquiries, seizing windows of opportunity for reform, and embedding accountability.
“Making genuine reform requires a commitment to parking responsibility at key individual and institutions’ doorsteps,” he writes.
Simon Katterl writes:
On 23 October 2018, then-Premier Daniel Andrews announced that if his Government was re-elected in the following month, he would establish a Royal Commission into Victoria’s Mental Health System.
He kept that promise and, on 2 March 2021, the Royal Commission was tabled its final report in Parliament. Premier Andrews acknowledged that: “The cost of our current neglect is clearly documented in this report. It demands … an urgent, concerted and effective response.”
He committed his Government to implementing all 74 recommendations.
More than four years on from the final release, and following Jacinta Allan becoming Premier in September 2023, progress on the reforms is slowing.
This month a Parliamentary Committee – the Public Accounts and Estimates Committee (PAEC) – revealed the Government’s underwhelming implementation of the recommendations:
- Only 11 of 74 recommendations (15%) completed after more than three years
- Six recommendations due by 2022 still “in progress” as of June 2024
- Seven recommendations with 2024 deadlines still “in progress”
- Three recommendations previously “In progress” reclassified as “To be commenced”.
Some stalled recommendations include establishing a Lived Experience Agency, shifting to health-led responses for mental health crisis, and eliminating seclusion and restraint.
We also don’t know the status of key recommendations such as a lived experience-led residential mental health service that has been designed but awaits funding to start serving Victorians.
PAEC reported that “DH did not provide specific reasons for overdue recommendations” and critiqued vague explanations, such as DH advising it had “re-sequenced initiatives for the next stage of reform” based on stakeholder consultations.
Current reporting doesn’t show “progress against sub-components of recommendations,” making it “difficult to accurately assess progress”.
The PAEC report found the Department failed on most performance measures:
- Only 46.8 percent of emergency department mental health patients transferred to a bed within eight hours (target: 80%)
- Only 45 percent of consumers reported positive service experiences (target: 70%).
Accompanying this is evidence that Victorian mental health services show major differences in their quality and performance.
The October-December 2024 reports show Peninsula Health had 0.0 seclusions per 1,000 bed stays, while Austin Health had 21.7. The government target is six seclusions per 1,000 bed stays, with only 39 percent of services meeting it.
Variations of this kind suggest serious issues in how the system is being regulated and the reforms being stewarded.
Understandably, people are asking, what is the Government’s commitment to implement the Royal Commission recommendations?
People accessing and using services are asking why there is minimal evidence of transformation in how Victoria’s mental health services are being governed, designed and operated.
This underperformance begs questions.
Four years into a reform process, I focus on what can we learn from this?
Below I unpack key lessons from the Royal Commission process.
Missing voices
Transformative thinking requires asking fundamental questions: Whose interests are prioritised? Who receives the greatest and most valuable resources? Who determines where resources go? Who are deemed experts? What is deemed ‘common sense’ or ‘radical’? What is the stated, real and hoped-for purpose of the mental health system?
The Victorian Government’s failure to ensure Commissioners were appointed to represent consumers and First Nations peoples undermined the Royal Commission’s ability to ask these questions, interpret evidence in light of them, and return recommendations that meaningfully responded to them.
What I’ve learned: Representation matters because those with expertise must shape the inquiry itself.
Narrow terms of reference
The terms of reference define what the Royal Commission can investigate, how it may proceed, and what recommendations it can make.
The Royal Commission’s focus reflected terms of reference the mental health system would have most accepted.
This included prevention, access to mental health services, supporting marginalised groups, person-centred care, workforce development, and system integration.
Absent from the terms of reference were investigation and restorative recognition of harms and abuse, and meaningful engagement with social determinants of mental health such as housing, family violence, and welfare.
If you believe that these all should have been included: I agree.
Yet the political challenge is real: if a Royal Commission investigated historical harms and social determinants, its scope becomes enormous – effectively an inquiry into government itself. And for the government, they would need to show results going into the next election should they wish to be re-elected.
These considerations show the challenge facing any government setting up an inquiry of this nature and the importance of finding the most impactful focus areas to drive change.
Given that the system looks much like it did before the Royal Commission, a preceding a restorative justice process or beginning the Royal Commission with a restorative justice process could have been more effective. This would involve greater efforts to decentre the power that maintains the current system.
What I’ve learnt: There will be no silver-bullet or ideal terms of reference. Instead, we should aim for the highest and most impactful focus areas so that we can sequence change over time.
Change in political leadership
Strong leadership is paramount for system-wide reform.
The “conviction politics” of Daniel Andrews initially cleared pathways for change, but this momentum waned.
The Royal Commission faced significant disruption as the ministerial portfolio changed hands from James Merlino – informally known as a hard taskmaster whose pressure drove implementation – to Gabrielle Williams to Ingrid Stitt, after which reform progress slowed noticeably.
The departure of Andrews and Jacinta Allan’s succession as Premier proved another blow. This was less about skill and more about political ownership, because mental health was seen as Andrews’ issue.
It hasn’t been clear that Allan plans to take on the reforms with the same vigour. These changes fragmented ownership of the Commission’s findings, diluted institutional knowledge, and weakened high-level advocacy when Victorians needed it most.
What I’ve learned: Take advantage of proactive leadership and political momentum. These are windows of opportunity.
Policy first
Paul Keating is often quoted saying ‘good politics is good policy and good policy is good politics’. I happen to disagree.
Good policy requires good politics, but not the other way around.
Tough on crime, not taxing corporations, environmental deregulation…the list of terrible policies that are good politics is long.
In an in-depth discussion with me during the Royal Commission process, Professor Fiona Haines, Professor of Criminology at the University of Melbourne, reflected on the difference between ‘risk’ when it comes to politics and policy.
Speaking about regulatory contexts after a disaster has occurred (think Three Mile Island partial nuclear meltdown), Haines reminds us that all reform is torn between ‘actuarial risk’ (a measurable risk based on likelihood vs impact), ‘sociocultural risk’ (risks to the collective ‘us’ in a community), and ‘political risk’ (a threat to political legitimacy for those who claim authority).
Despite conclusions that ‘little data is available on the impact and efficacy of the billions of dollars invested by governments across the system each year’, clinical solutions have been prioritised ahead of lived experience-led solutions and rights-based reforms and actions to this point.
Part of this, in my view, relates to how restrictive mental health hospitals tap into sociocultural risks based on stigmatising attitudes about ‘dangerous’ and ‘sick’ people in mental distress. Therefore, political legitimacy for governments have to date relied upon funding these kinds of supports.
Transforming mental health systems requires addressing sociocultural and political risks by redefining the legitimate purpose for the system. That requires a shift from “treating illness” to “supporting self-defined good lives.”
Restorative justice processes can identify current failures in the current purpose of the system, chart a path to a better purpose of the system, while centring lived expertise. Done well, it does so in ways that heal and reconfigure relationships between people who use and provide services.
What I’ve learnt: Large-scale mental health reform must engage with and shift the political in order to achieve the policy outcomes we seek.
Accountability matters
An absence of accountability undermines justice and momentum for change. The Royal Commission leaned heavily on ‘the system is broken’ diagnosis – language regularly used by Andrews.
But as Simon Stafrace wrote in The Age, ‘the system wasn’t broken; it was built this way.’
The better question is whose interests is the system serving? A system persists –despite harmful outcomes – when it serves powerful interests that hold it in place.
The Royal Commission – hampered by a lack of consumer and First Nations commissioners and harm-focused terms of reference – didn’t engage with these questions deeply. It’s hard to find strong criticisms of any actor in its report.
The ‘broken system’ narrative concealed a key point: systems are driven by interests, institutions and leaders. Without surfacing that key point, we were always at-risk of applying paint over cracks.
The Mental Health and Wellbeing Commission has not brought accountability promised by the Royal Commission. Keeping largely similar regulatory functions, it has received over 18,000 complaints without issuing a single compliance notice. They claim alternative means of effectiveness through voluntary recommendations, but are appealing a directive to release those recommendations.
The accountability gap extends to how the Mental Health and Wellbeing Commission is holding the Victorian Government accountable for Royal Commission recommendations.
The Commission has a statutory responsibility to monitor and keep the public informed on implementation progress.
And yet, PAEC reported: ‘In its Annual Report the MHWC published a table provided by DH showing the progress made on implementation of the recommendations. However, it does not show progress against the sub‑components of recommendations’.
Indeed, in many cases PAEC obtained more information than the Commission did, despite the Commission having the power to open an inquiry to compel that information.
What I’ve learnt: Without accountability, the ‘broken system’ narrative merely shields individuals from responsibility while preserving harmful status quo. Making genuine reform requires a commitment to parking responsibility at key individual and institutions’ doorsteps.
Lived experience holding the can
James Baldwin wrote: “If one really wishes to know how justice is administered in a country, one does not question the policemen, the lawyers, the judges, or the protected members of the middle class. One goes to the unprotected – those, precisely, who need the law’s protection most – and listens to their testimony.”
This is equally true in mental health. But Baldwin is talking about understanding justice, not who should bear the burden of driving change. It’s the policemen, lawyers, judges and protected members who may be producing injustice and who must change or be removed.
The Royal Commission has thankfully seen the elevation of lived experience. Coming from an era where those of us with lived experience have never been conceived of as valid knowledge holders, this inclusion can be positive.
However, lived experience becomes mere veneer representation when deployed to create the illusion of change without shifting power – showcasing individuals without altering institutional behaviour.
True change requires dismantling oppressive structures, redistributing power, and fostering accountability, not just including diverse voices.
At its best, lived experience can prompt deep dialogue and collective reimagining; at its worst, it’s a pressure-releasing activity that dulls our consciousness about the need for immediate, substantial change.
What I’ve learned: Lived experience representation, while necessary, is insufficient for authentic transformation. How we gauge that authenticity is to look closely at the work being done around that representation. The test is whether power truly shifts or whether inclusion becomes a substitute for genuine change.
Where to?
Victoria remains only four years into a ten-year reform era. But rather than renew energy for transformation, leadership changes have presaged further decline.
The questions for Victorians in the sector are complex. Should we renew the reform agenda with political capital and urgency? Or should we imagine beyond the reform agenda?
More broadly, questions come from whether we can deliver large-scale reform in the second quarter of the 21st century. Royal Commissions have come and gone with mixed success. Electorates may have limited appetite for further inquiries.
Whether or not future inquiries are sought to address policy problems, it’s helpful to remember that policy reform once occurred without Royal Commissions.
Medicare, the NDIS, public broadcasting, the Pharmaceutical Benefits Scheme – these were all enormous reforms that we take for granted but were unimaginable before their creation. So, there was a way.
I still believe there is a way. But we need to understand how we got here before we decide where we go next.
• Simon Katterl (he/him) is a mental health consultant and advocate with lived experience of mental health issues.
See Croakey’s archive of articles on Royal Commissions
Let us ask:
Do we live in a world in which everybody takes care of the health of our planet’s air, waters, soils, lands, plants, and animals, in various ecological (tropical, temperate, and polar) habitats, and everybody takes care of the health of basic social supports (water, food, health, education, income and work, peace and justice, political voice, social dignity, gender equality, housing, networks, and energy) in the lives of every person in all families in all generations in all communities in healthy sustainable societies?
Do we live in a world in which everybody lives with sufficiency within the carrying capacities of our ecological habitats and with secure social supports during their lives across all generations?
Australian media tends to claim that Australians have a choice between Labor and Coalition parties.
Both parties, however, tend to be puppets of corporate interests, which tend to be focused on unlimited economic growth (unleashing boundless greed in people and businesses) on our finite planet.
Neither party care enough about their key responsibilities in supporting human development-wellbeing, from me-centred child to us-centred adult to all-of-us-altogether elder (see, for example, Plato’s Allegory of the Cave, Abraham Maslow’s Hierarchy of Needs, Robert Kegan’s Orders of Consciousness, Susanne Cook Greuter’s Ego Development Theory, Terri O’Fallon’s STAGES, Said Dawlabani’s Second Sapiens, or any other reading of human development from child into adult into heart-centered sage) in everybody in all generations.
Neither party do what is necessary to live within the limits of the carrying capacities of our ecological habitats (see Planetary Health Check 2024), nor do what is right for everybody to have secure social supports during the course of their lives (see Doughnut Economics Action Lab) in a healthy sustainable society.
Instead, both parties tend to allow the exploitation of all sorts of marginalized peoples (what percentage of children are now living in poverty in Australia?) and to allow the extraction of all sorts of resources from life on our planet in their current pursuits of survival, greed, wealth, and material power.
Both parties tend to ignore universal human rights that secure basic dignity in the lives of all human beings and both parties tend to ignore Nature’s rights that secure quality of life for all living beings in Sacred (Spiritus-anima-corpus) Nature (Philos-Sophia Initiative Foundation » Surveying the Integral Cosmos).
So, Human Rights Watch World Report 2025 reports, “Australia remains the only Western democracy without a national human rights act or charter.”
To be “mentally healthy” within Australia’s exploitative and extractive economy is to be poor in our full (Spiritus-anima-corpus) humanity, and in our rich Spiritus-anima-corpus interconnections with life in all living beings.
We do not live in a democracy in which government works creatively and consultively with the people to find the best dates forward in any field. We live in an oligarchy where the wealthiest corporate giants exploit the adversarial party political system with the Parties only seeking to convince the public that their side’s plans are best. Party-backed members of parliament are compelled to vote in Parliament as the inner circle of their Party tells them to. So how can those members of Parliament then act as or claim to be representatives for their electorate on the basis of policy promises that are not legally binding anyway. Members of Parliament are not required to actively canvas their constituents’ opinions on any topic or policy or to publish the results of any such research. There is no law mandating truth in political advertising. Nor to reveal which corporates or lobby groups have had access to departmental ministers or political party executive or cabinet groups. Successive governments of Australia have ceded Australian sovereignty to greedy, global giants, not least through free trade agreements that operate unaccountably completely outside the Australian legal or parliamentary system, but can impose multimillion dollar penalties to be paid by the Australian taxpayers. Beggars and homeless on Australian streets – unthinkable until the”opening up” of Australia to unrestrained global operators and exploitation without regard to environment or social justice or equitable contribution to the common wealth of the Australian people through taxation on the basis that their headquarters are in Dublin or the Seychelle Islands for examples. What chance then for social justice and the funding it requires – free education including tertiary courses for all Australian citizens, a living wage for full time parents and unemployed workers without work because of tax-payer funded subsidies for ever more machines that replace human workers. Human rights to food, shelter, education literacy and numeracy, to choice, movement and justice. ??????