The Royal Commission into Victoria’s Mental Health System delivered its final report on Tuesday, describing “catastrophic failings” in the system including over-reliance on medication, compulsory treatment and acute care, and where too many people are turned away from supports and services, “often in their darkest hour”.
Urging transformation of the system — a new road versus filling in the potholes — the Royal Commission delivered 65 recommendations in a massive 3,000 page, five-volume report that reportedly weighed 13 kilograms as a hard copy.
While many in the sector (and at Croakey) were still working their way through its pages late in the day, the report has won early support from many stakeholder groups for strongly embedding the voice of people with lived experience in design and delivery of services and reorienting the system towards community-based treatment and away from hospitals and acute care.
Some of its key reforms include establishing a new Mental Health Act, a new Chief Officer for Mental Health and Wellbeing in the Department of Health, and a new agency and services led by people with lived experience to support the development of organisations and services led by and for consumers.
Other recommendations include two on-Country healing centres for Aboriginal people, the rollout of up to 60 new local mental health and wellbeing services in community, new family and carer-led centres across the state, and an independent Mental Health and Wellbeing Commission to hold the Victorian Government to account.
Shocked by evidence
Delayed by the pandemic last year and again by the latest COVID-19 lockdown in Victoria last month, the Royal Commission report was finally tabled at a joint sitting of the Victorian Parliament, meeting at Melbourne’s Royal Exhibition Building to ensure all MPs, witnesses and participants could attend, adhering to COVID-safe rules.
Royal Commission Chair Penny Armytage told the joint sitting she had been personally shocked by what she had seen and heard during the course of the Royal Commission, which was launched in 2019 by Premier Daniel Andrews, who declared the system “broken”.
“The system wasn’t compromised in part, its foundations were broken,” Armytage said, declaring the Royal Commission has sought through its recommendations to establish a new system built on compassion and where, “for those in crisis, police and ambulance call-outs and emergency departments will no longer be the only options.”
For too long, the profound human societal and economic toll of a failed system has been ignored. We know that a collection of discrete reforms to an antiquated system is not viable. We have recommended a fundamental redesign.”
We have moved beyond filling in the potholes, we have created an entirely new road.”
Here are some key takeaways from the report and event.
1. Catastrophic failings steeped in stigma and discrimination
Armytage declared Victoria’s mental health system had “catastrophically failed to live up to expectations and is woefully unprepared for current and future challenges”.
The 2019-20 severe bushfire season and COVID-19 pandemic had “shone further light on the pressures on the system”, which had been failing people for decades, she said, quoting the lived experience of mental health advocate Honor Eastly:
“It wasn’t until I started working in advocacy that I started to understand that a big part of what I was struggling with was a broken and traumatic system. I had up until that point thought that what was happening was because I was a broken and ill person.”
Armytage described an utterly under-resourced system, where the average mental health service hours are estimated to be just two hours per person per year, meaning typically that the system “offers too little too late” and last year responded to less than one-third of estimated demand for community-based services.
“Again and again we heard from people and their families, at times in harrowing detail, about the negative impact of being told that they were not sick enough or not suicidal enough to access services and the sometimes tragic consequences of this,” she said, describing also “appalling” abandonment of carers, especially young family members.
Importantly, Armytage said the failings of our community to demand a mental health system as strong as the rest of our health systems “is much about the stigma and discrimination against people living with mental illness”, which explained why “complacency and meagre expectations have stifled reform and why the mental health system has been relegated to the shadows”.
2. Big commitment to reform….so far
Unlike the Federal Government’s approach so far to the Royal Commission into Aged Care, holding off from any announcements on what recommendations it will support, the Victorian Government promised from the outset, and reaffirmed on Tuesday, that it would implement every recommendation from Victoria’s Mental Health Royal Commission.
“No matter how long you’re in government, you only get a handful of days to do something that is truly profound, something that will change lives and save lives,” said Premier Daniel Andrews. But he warned that change won’t be “easy and quick” and said the final report would serve “as our blueprint for the biggest social reform in a generation”.
While the proof will be in the pudding — people working in the family violence sector have complained that implementation of some of Victoria’s Family Violence Royal Commission recommendations were ‘tick a box’ exercises, Premier Andrews said Victorians had declared they would “pay the price of failure [in mental health] no longer”.
Andrews said the Royal Commission report had been “shaped profoundly” by those who know our mental health system best – “the people who have turned to it, the people who have worked in it, the people who have been failed by it”.
Their courage and commitment had “laid the foundation for this once-in-a-generation reform,” he said, promising significant announcements in the May Budget on implementation.
3. Shocking breaches of human rights
Chair Armytage said under-resourcing of Victoria’s mental health system has led to an over-reliance on medication and too little offered by way of therapeutic and recovery-oriented services, meaning that many people who access services are not treated with dignity and respect and had their distress and trauma “compounded” by the system.
Echoing the shocking findings of the Aged Care and Disability Royal Commissions, she said “sadly, inpatient units too often feel frightening and unsafe”, with an “entrenched and unacceptable” prevalence of interpersonal and sexual violence particularly towards women.
Mental health consumers also had their human rights breached through the use of compulsory treatment, seclusion and restraint, and not as last resort, she said, again quoting a person with lived experience.
I reflect on three compulsory admissions with sadness. I wonder how my mental health trajectory would have been different if the GP I had seen in the lead-up to my first admission had organised an urgent psychiatric referral and I’d been supported to sleep . . . If the crisis assessment and treatment team had come the first time I called them and helped prevent my second admission . . . If the private hospital had treated me adequately rather than discharging me and prevented my third episode.”
4. Workforce in “moral injury/distress”
Armytage, leading mental health expert Professor Patrick McGorry, who headed the Royal Commission’s expert advisory committee, and Premier Andrews each highlighted the pressures on the mental health care workforce, who face “moral distress” — a desire and knowledge to do the right thing but in a system of constraints that “makes it impossible to do so”.
5. Social determinants on the agenda
Unlike the recent Productivity Commission inquiry into mental health, the Victorian Royal Commission reforms look beyond the mental health system, “recognising that other social services such as housing and education, the justice system and the places we live, work, learn and connect in, shape our mental health and wellbeing”.
The Royal Commission says stable housing is a key pillar to overcoming inequities and that it has ensured that people living with mental illness “will be recognised as a priority population for housing”.
It also understood that while poor mental health “does not discriminate”, some people, including from Aboriginal, LGBTQ+, refugee, CALD and disability communities experience additional barriers.
In recommending a holistic approach, Armytage said the Royal Commission had drawn on the knowledge long held by Aboriginal people and other diverse communities that “connection to land, culture, spirituality, family and community all influence mental health and wellbeing”.
In specific and wide-ranging recommendations (p131) for Aboriginal people, the Royal Commission has called for the delivery of two on-Country healing centres, which were among recommendations made by the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) in its Balit Durn Durn report, developed to support the Final Report.
“For too long Aboriginal people have fallen through the cracks of a fragmented and culturally unsafe mental health system,” VACCHO CEO Jill Gallagher said. “These two new centres will support resilience, healing, and trauma recovery through fostering connections to Country, kinship, and culture.”
Responses from key stakeholder groups
Below are responses from key stakeholder groups. We will add more as they are published.
See also this Twitter thread from mental health survivor researcher Indigo Daya.
VACCHO: welcomes healing centres, child supports
As well as the two on-Country healing centres (see above), the Victorian Community Controlled Health Organisation (VACCHO) welcomed recommendations from the Final Report for further investments for VACCHO to lead and establish appropriate family-oriented services for infants and children who require intensive social and emotional supports.
CEO Jill Gallagher said that, through the Balit Durn Durn report, for the first time in history, Aboriginal leaders, Elders, organisations, people, families, carers, and communities were given the opportunity to have their voices and experiences included in a redesign of Victoria’s mental health system.
She warned that, as Victoria emerges from COVID-19, mental health remains the community’s greatest challenge.
“We are hearing firsthand how hard many of our Communities have been hit from the fallout from COVID-19,” she said, warning that while suicides did not increase last year, clusters in Victoria remain of concern.
VHA: “report highlights deep cracks”
Victoria’s public health peak body, Victoria Healthcare Association, welcomed many of the recommendations in both interim and final reports for the focus on workforce, rural and regional access, governance, prevention and early intervention, key areas identified by the sector as fundamental to reform.
“The final report highlights the ‘deep cracks’ that exist in the system and the VHA is pleased that many of our sector’s recommendations and ideas are reflected in the final report,” VHA chief executive Tom Symondson said, urging immediate implementation.
The VHA particularly welcomed:
- The creation of a new Mental Health and Wellbeing Act to underpin an integrated statewide mental health system.
- The implementation of a new whole-of-system rehabilitation pathway, which includes two new bed-based rehabilitation models of care.
- The establishment of a new Statewide Trauma Service.
- The development, funding and implementation of modern infrastructure for ICT systems, including a new statewide electronic Mental Health and Wellbeing Record.
- The creation of a new Mental Health and Wellbeing Commission to monitor progress and hold the Victorian Government to account.
- Additional resourcing and a workforce incentive scheme for mental health services in rural and regional areas.
However, the VHA said it has some concerns about the proposals to use activity-based funding for bed-based and community-based mental health and wellbeing services and would prefer a more person-centred and responsive funding approach.
Symondson said the final report “marks a turning point in the state’s design and delivery of reforms to support the mental health of Victorians”, adding that the public health sector is “committed to integrating lived experience into the system”.
MHV: “most significant reform since de-institutionalisation”
Mental Health Victoria said the report was “the most significant development in mental health since de-institutionalisation in the 1990s” and articulates a “bold new vision for mental health service design, commissioning, delivery and governance” that should be taken up by other states and territories.
“For too long, Victorians have had few options but to present to hospital emergency departments or to suffer in silence. The reforms announced today will change all that,” said MHV CEO Angus Clelland, who added they had “set a very high bar for Victoria”.
“Once the reforms have been implemented, the Victorian system will become the national benchmark. We hope that the other states and territories follow Victoria’s lead.”
He said the reform process will create thousands of new mental health jobs across Victoria and across all mental health disciplines – including peer workers, nurses, social workers, occupational therapists, psychologists, psychiatrists and community workers.
CHP: “stable housing core part of care”
Council to Homeless Persons CEO Jenny Smith welcomed the recognition by the Royal Commission of the importance of safe, supported, appropriate accommodation for people living with mental illness.
“The commitments to strengthen community-based supports, and to significantly increase the amount of supported housing options available will make a real difference in the lives of Victorians experiencing homelessness and mental illness,” Smith said.
“We also welcome the Commissioners’ recommendations to strengthen culturally appropriate care for people living with mental illness, support to people experiencing trauma, and effective support to people living with addictions as well as mental illness.
“It is also very positive to see that the Commissioners have highlighted the importance of strongly embedding the voice of people with lived experience in design and delivery of mental health services.”
Cohealth: “placing clients at the centre of care”
Not for profit community health organisation cohealth said the delivery of the final Report from the Mental Health Royal Commission was an emotional day for those who have been failed by the system, as well as the people who support them.
“The Royal Commission process revealed what we have long known – our mental health system is full of gaping chasms stitched together by underfunded services, and is over-orientated towards acute care,” Chief Executive Nicole Bartholomeusz said.
Bartholomeusz applauded the Commission’s vision of a mental health and wellbeing system that places clients at the centre, and strongly reoriented towards community-based treatment, care and support as an alternative to hospital or crisis-based care.
RANZCP: “encouraged” but warning on workforce shortages
Royal Australian and New Zealand College of Psychiatrists President-Elect Associate Professor Vinay Lakra said he was “encouraged” by the once-in-a-generation opportunity for reform, and welcomed measures it had advocated for, including ensuring provision of ongoing intensive treatment, care and support for people with severe mental illness, facilitating suicide prevention and response initiatives and embedding a trauma-informed approach in the mental health system.
However, the RANZCP Victorian Branch said there remains an integral need for workforce shortages to be addressed, particularly specialist staff shortages, and a well-funded and long-term approach to implementing the recommendations.
“We welcome the report’s acknowledgement of the exhausted and overburdened workforce, and the moral distress of trying to provide care in a broken system,” the branch said, urging that measures to “expand the psychiatry training pipeline” be a key priority for the Victorian Government.
“We look forward to supporting the Victorian Government to fulfill its promise of implementing all recommendations made by the Royal Commission into Victoria’s Mental Health System but caution them to do so in a careful and considered manner to ensure that we build and safe and inclusive mental health system for all,” it said.
Legal Aid Victoria: “places human rights at centre”
In its statement, Legal Aid Victoria highlighted a number of reforms including:
- A new Mental Health and Wellbeing Act to provide the basis for transformational reform.
- An independent Mental Health and Wellbeing Commission, including a Commissioner with lived experience, to improve the quality and safety of the system and monitor the Victorian Government’s progress in implementing the recommendations.
- Targets to reduce the use and duration of compulsory treatment, and to work towards eliminating the use of seclusion and restraint.
- Ensuring people at risk of or subject to compulsory treatment can access non-legal advocacy.
- Increased access to legal assistance for people subject to compulsory treatment.
- Increased mental health support for people in custody and when they transition out of prison.
- Recognition of the importance of responding to trauma through the creation of a statewide trauma service.
- Specific measures to address stigma and systemic mental health discrimination.
‘The final report places human rights at the centre of the new system, emphasising that rates of compulsory treatment must be radically reduced, and it must only be used as a last resort,’ said CEO Louise Glanville.
See this statement also from the Federation of Community Legal Centres.
SPA: looking also to PM’s response
Suicide Prevention Australia particularly welcomed the recommendation to establish the Suicide Prevention and Response Office but warned that the future State Suicide Prevention and Response Adviser needs to maintain a focus on suicide prevention as a separate issue to mental health.
“Suicide Prevention Australia has long been advocating for a whole-of-government approach to suicide prevention, and we are happy to see the Victorian Government taking the first steps toward integrating suicide prevention into every department,” CEO Nieves Murray said in a statement, also welcoming the recommendation for peer-led safe spaces and gatekeeper training across communities and workplaces, and for supporting people after a suicide attempt.
Murray noted the organisation was “still eagerly awaiting” the Prime Minister’s response to the interim report from the National Suicide Prevention Adviser “which could be a game changer”.
ANMF: welcomes ‘how can we help?’ focus
The Australian Nursing and Midwifery Federation (Victorian Branch) welcomed recommendations to mend the mental health system based on a philosophy of ‘how can we help?’, saying many aligned with its submission, including fixing funding, retaining clinical mental health services in the hospital system, removing fragmentation between services and improving the safety of the mental health workforce.
‘We won’t rest until the abolished yet successful federally-funded mental health community nurse program, known as the ‘Mental Health Nurse Incentive Program or MHNIP’ is restored and supporting people with complex, often trauma-based mental illness to stay well and living, working and learning in their communities,’ said Assistant Secretary Madeleine Harradence.
The ANMF (Vic Branch) asked for and supports the establishment of Adult and Older Adult Local Mental Health and Wellbeing Services and Area Mental Health and Wellbeing Services designed to provide integrated, holistic care, support to navigate the system and shared care between primary and secondary services.
The report acknowledges that the broken system has harmed not helped many of those who took the difficult step of asking for support and also acknowledges the trauma mental health nurses and others, working in an under-resourced and disconnected system, have experienced because they were unable to meet the overwhelming needs of unwell Victorians, she said.
“Recommendation 58, which addresses workforce safety and wellbeing, will be critical to ensuring nurses, doctors and allied health professionals are safe at work and in a position to provide the best care possible.”
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