Introduction by Croakey: Many concerns and questions have been raised about Australia’s mental health commissions, the constraints under which they operate, and their failure to drive meaningful health reform.
Below, Associate Professor Sebastian Rosenberg and Professor Alan Rosen – who collectively hold many decades of experience in mental health reform efforts – put forward recommendations for ensuring mental health commissions can operate as “genuine agents for lasting, positive mental health reform”.
Sebastian Rosenberg and Alan Rosen write:
We have been strong supporters of mental health commissions, as new system oversight and enhancing structures designed to drive real and sustained reform.
We’ve developed an international typology for them, advocated for them, worked on co-creating them, developed legislation for them, been on them, and proposed criteria for their evaluation. We welcomed them.
We have also been concerned about them being distracted, co-opted, even neutered by different government administrations, as described in this recent paper published in The Medical Journal of Australia (MJA).
The findings of the review into the National Mental Health Commission were presented by Minister for Health Mark Butler in September 2023. Of most significance was the finding that the Commission palpably lacked the key strategic and technical skills to develop and publish its promised National Mental Health Report Card and was operating without strategic or operational work plans.
This review focused on maladministration and morale, however, not strategy.
Other reviews or evaluations of Australia’s seven mental health commissions (only Tasmania and the Northern Territory do not run a commission) provide little comfort.
The New South Wales review reported that the role of the Commission there had become “less relevant and effective”, and that it needed to refocus around performance monitoring and accountability.
Survey responses to the Queensland review highlighted the challenges faced by that Commission in working across government and non-government agencies to influence system reform. A mid-term review of the Australian Capital Territory Office for Mental Health and Wellbeing was undertaken by the ACT Government itself, rather than independently.
Western Australia’s evaluation
Overall, Australia’s well-intentioned investment in mental health commissions remains largely unevaluated, with one exception.
In 2019, the WA Auditor General tabled an evaluation of the extent to which the mental health commission in that state had met its objectives since its inception in 2010.
Uniquely, the WA Commission had been quite explicit in stating its goals. Unlike the other commissions, WA’s holds the budget for mental health services, as if it was the Department of Mental Health.
All the other six commissions do not hold the budget. Rather, they purport to influence how government strategically funds mental health, and how other agencies spend, protect and grow that spend.
Despite significant problems in piecing together the requisite data, the Auditor General was eventually able to report that the proportion of hospital-based care in WA had increased from 42 percent to 47 percent, further away from the targeted reduction to 29 percent the WA commission had hoped to achieve by the end of 2025.
It also reported that the proportion of funding towards community treatment services remained the same at 43 percent but that the proportion of funding for both prevention and community support had decreased instead of steadily increasing (from three percent to one percent, and eight percent to five percent, respectively).
Key markers were heading in the wrong direction. Still, at least there were markers.
Commissions and resourcing
The MJA article presented data showing that of jurisdictions with commissions, only in the ACT had the rate of growth in mental health spending outstripped total health spending.
Over the period from 2010 to 2021, for example, total health spending in NSW increased by 35.5 percent but for mental health specifically, only by 22.4 percent.
Put another way, mental health’s share of total health spending in NSW declined by just under 9.7 percent between 2010-11 and 2020-21.
Overall, the data suggest that commissions have struggled to deliver any more resources to mental health.
All the commissions bar the one in WA are small agencies, with annual budgets of less than $10 million. Out of the $11.5 billion spent on mental health in Australia in 2022, only a very small proportion, less than one percent, was allocated to this kind of systemic oversight.
It is unreasonable to lay all the blame for stalled progress on mental health reform entirely at the feet of these small agencies.
It is not easy to persuade health or other departments to change what they fund or how services work even if, as in WA, you hold the budget!
Revamping commissions
Mental health commissions might still represent an important opportunity to drive a positive reform agenda.
But if this is to be the case, they need strong government (and broader) support to focus effectively on core tasks and recruit people with the right skills and determination to lead them.
These tasks include:
1. Independent monitoring
Commissions must be constituted with proper independence and the political authorising environment to enable unfettered advice, inquiry and reporting.
This is not the case currently, with most sitting as part of health departments (ACT and nationally, for example).
Others, such as NSW, have chosen not to use the ‘teeth’ they already have, had their teeth pulled or struggled to assert their role in the face of much larger government agencies.
2. Amplifying voices
A key part of independence too, is the capacity of commissions to collect and reflect the unalloyed voices of lived experience and family experts in our mental health system.
This would probably be one area where existing commissions would feel that some progress has already been made. This must continue.
Connections to the new national peak consumer and carer bodies will be important. Commissions also need to amplify the voices of depleted teams of service providers, whether clinicians, psychosocial, support or peer workers.
3. System principles
Our mental health system is a clash of different funding streams, including Medicare, the NDIS, primary health networks, the public hospital system and private insurance.
Commissions should play a key role in establishing common principles and strategies that surmount these silos and provide a new, ethical framework for equitable, quality, contemporary mental healthcare.
For example, mental health hospital avoidance programs have been part of the National Health Reform Agreement for a decade.
The scientific evidence clearly demonstrates that the local community is the most desirable service location for people needing mental health care and healing. Over recent years, this goal has become more remote.
Most mental health spending still directed towards hospital-based care while, in several jurisdictions, funding for community mental health teams has been diverted, diminished and withdrawn to hospital sites, forcing them to operate now more like traditional sedentary outpatient departments. Why?
4. Design
New foundational support and out of hospital support streams now seem possible in mental health, potentially perpetuating further confusion based on funding streams.
Commissions could help here, focusing on role and service clarity – aiming to end the fragmented, disorganised approach that characterises our existing response to mental illness.
Commissions could help build and present the evidence about what services should be available to whom, from whom, for how long, with what expected outcomes and what should happen if the person gets better or sicker?
They could usefully apply holistically all the facets of complexity science to help regions to better understand and respond intelligently to their mental healthcare ecosystems.
The absence of this work, together with inadequate funding, creates the gaps through which people with mental illness now fall.
5. Funding
Commissions need to track regional services and funding, aiming to promote both equity and quality.
Commissions should also be key advocates for bridging the significant gap which still remains between mental health contribution to the overall burden of disease (15 percent) and its share of total health expenditure (6.78 percent).
6. Accountability
The final element demonstrating the merit of commissions as change agents would be the one which underpinned their inception – their capacity to fairly hold the mental health system to account.
This does not mean blame. This means ensuring funding allocated to mental healthcare goes to mental healthcare.
It means building linked data systems that can reasonably establish the regional benchmarking necessary to drive systemic quality improvement. This kind of benchmarking was a hallmark of the NZ Mental Health Commission in its hey-day. This may be possible again if they can return to bipartisan esteem and support, which their commission achieved in the past, and which is worth pursuing in Australia too.
This means joining health, housing, employment, education and other data, from government and non-government sources, to build a fair and useful picture of the extent to which the mental healthcare provided helped people get their lives back on track.
For example, the Canadian Commission had a key role in the largest supported “Housing First” initiative and implementation research for homeless people with mental disorders in the world.
Way forward
Genuine effort at these tasks would create a compelling case for mental health commissions, particularly if they became a nationally consistent, rapidly evolved collaborative network, properly organised, staffed and supported to become genuine agents for lasting, positive mental health reform.
This means building commissions up, rather than tearing them down. It means ensuring they develop, protect, exercise and hone their arm’s length monitoring and evaluation skills.
They need statutory powers and independent delegations. They need skills in data gathering and analysis as well as strategic planning, interdisciplinary mental health expertise and a strong concern for human rights.
As in WA, and even if considered politically risky, commissions and their governments must be brave enough to develop explicit and comparative reform goals, indicators and targets against which to assess progress, and mechanisms to ensure the integrity of both mental health budgets and expenditure.
A key part of building momentum for this will entail the transparent, independent and regular evaluation of the impact of all the commissions themselves, and of the authorising environment in which they are permitted to work. We do not underestimate the complexity of the tasks they face.
Australia’s adoption of the commissions model, in most jurisdictions and federally, is globally unique, perhaps reflecting our desire for a mission-focused agency or closeknit consortium to surmount the complex, fragmented nature of Australia’s mental health care system with its compelling problems.
The challenge now is to make the most of this opportunity.
Author details
Associate Professor Sebastian Rosenberg, Health Research Institute, University of Canberra and Brain and Mind Centre, University of Sydney, former expert facilitator of taskforces to form NSW Mental Health Commission and ACT Office of Mental Health and Wellbeing.
Professor Alan Rosen, AO, community psychiatrist, Brain & Mind Centre, University of Sydney and Australian Health Services Research Institute, University of Wollongong, former member of Taskforce to form and former inaugural deputy commissioner, NSW Mental Health Commission.
See Croakey’s archive of articles on mental health
