But before we come to its findings (which are summarised below, together with the launch address of Commission chair, Professor Allan Fels), let’s take a few minutes to consider some of the wider context.
• We live in a society which tolerates the incarceration of vulnerable and traumatised people who have not committed a crime, including children. As University of NSW researcher Belinda Liddell writes at The Conversation:
“Current immigration policies continue to promote uncertainty, fear and disempowerment among asylum seekers, which are known to contribute to poor mental health. There are also concerns that allowing asylum seekers to live in the community on bridging visas without the right to work could further exacerbate these feelings of helplessness.”
• We live in a society where the wounds of racism are prevalent. According to this recent report, Mental health impacts of racial discrimination in Victorian Aboriginal communities, documenting the experiences of 755 Aboriginal people, 97% of those surveyed had experienced racism in the previous 12 months, and over 70% experienced eight or more racist incidents. Imagine the stories of those experiences and their impact upon health and wellbeing. Meanwhile, the Australian Financial Review has reported on the sexist and homophobic jokes told at an Australian Hotels Association function.
• We live in a society where governments are unable or unwilling or too cowardly to take on the industries which have such a profound impact upon mental health at a community and an individual level – (I’m thinking alcohol and gambling, in particular).
• We live in a society which pays a great deal of lip service to the importance of children and parenting, but is prepared to sacrifice children’s health to corporate profits, and to add to the burden of single mothers. According to a report in The Australian (sub only unless you google the headline), single mothers are being advised to turn to charities when their government allowance is cut back:
“Centrelink officers are advising single mothers who say they will not be able to cope when they lose welfare money under a budget savings initiative that begins in January to contact charities for help.
The government has come under fire, including from some Labor backbenchers, after passing laws to move single parents on to Newstart payments when their youngest child turns eight.
The changes will save the government $728 million over four years and will cost single parents up to $223 a fortnight…”
• We live in a society where the virtues of employment are regularly extolled but far less attention is paid to the distress caused by insecure work. Consider the ACTU inquiry report, Lives on Hold: Unlocking the Potential of Australia’s Workforce, which documents the toll that insecure work takes on individuals and family finances, health and wellbeing.
The inquiry learnt of one manufacturing plant in western Sydney where the entire staff were employed as casuals through a labour hire firm. Employees were expected to be available for a full-working week, and were notified by text message around 4pm each day of whether and when they were required to turn up the next day – but without any information about how long their shift would be.
These are some of the wider issues that should be part of our conversations about mental health and suicide prevention, beyond the provision of services.
Now to the report.
It frames mental health as a human rights issue, a community issue, and a life and death issue, and promotes the value of a “contributing life”.
It encourages us to see the importance of the interconnections between services, the place of families and support people, health care providers, co-workers, and teachers and friends.
It stresses the importance of listening to and learning from peoples’ experiences: “The three straightforward messages we heard from the remote Aboriginal community of Ltyentye Apurte (Santa Teresa) ring true wherever we go – “Listen to us, involve us in decisions that affect us, support us to make our recovery successful.”
It includes a focus on:
- Aboriginal and Torres Strait Islander peoples’ mental health and wellbeing.
- The physical health of people with a mental health difficulty – which is worse than the general community on just about every measure.
- Connections with family, friends, culture and community, and participation in personally rewarding work, employment and community involvement.
- Housing (It notes, for example: The Commission is deeply concerned that since 2008, despite some attempts, thereis still no reliable and robust national measure of exits into homelessness from human services or government mental health and drug and alcohol services and centres. This is an absolute priority for the Commission and should also be one for Australia), and
- Preventing suicide.
It identifies four priority areas
1. Mental health must be a high national priority for all governments and the community
The Australian Government must ask the Productivity Commission to work in partnership with us to report on the economic and productivity impacts of mental ill health and suicide in Australia and the value of
good mental health.
2. We need to provide ‘a complete picture’ of what is happening and closely monitor and evaluate change
There are over 75 national mental health indicators, but these focus too heavily on health services. It is currently almost impossible to get a good picture of whether support is effective. Data doesn’t always show the important work being carried out in the community or by private providers or the important role that families, support people and peer workers provide.
It doesn’t tell us if people’s lives are improving, whether they are being treated with respect, or whether we have got the balance right in where we spend money.
Data must be rationalised and the right data collected with better linkages between data sets.
All governments must independently and transparently report each year on the actual expenditure on mental health prevention, community based, rehabilitation, recovery and acute care services and compare this with the announced expenditure. This way we will know that money committed to mental health is actually used in mental health, is used in the right areas and is not used to offset funding pressures or subsidise shortfalls in hospital or related budgets.
3. We need to agree on the best ways to encourage improvement and get better results.
The Independent Hospital Pricing Authority (IHPA), which develops the ‘national efficient price’ for public hospital services must have the authority to price an annual package of support that meets all of the health needs of people with mental health difficulties. If not, COAG will have got it wrong. We hope that COAG continues to drive improvement in mental health services and not push services back into hospitals. This will be more costly and less effective all round.
The National Disability Insurance Scheme must fully cover the psychosocial disability that results from mental illness.
4. We need to analyse where the gaps and barriers are to achieving a contributing life and agree on Australia’s direction.
All governments must prioritise the development and implementation of a nationally agreed mental health service planning framework. Unlike Canada and New Zealand, Australia has no nationally agreed picture of what a good mental health service framework should look like and how it should be properly resourced, nor of the role that families and support people should play in such services.
The framework should tell us what services people should get regardless of where they live, so there is the best use of resources to support people to gain the most improvement.
It must give a clear picture of the appropriate coverage, levels and range of mental health services needed at a regional level along with the workforce mix needed to deliver it.
A national service planning framework must over time move beyond beds and clinical services and include non- government/community services across all sectors, including peer and family workers.
COAG should give the Commission the role of monitoring progress against the Ten Year Roadmap for National Mental Health Reform to assist in driving reform between government and other service providers. The Commission must be given access to the data needed to do this properly.
The report’s ten recommendations
1. Nothing about us, without us – there must be a regular independent survey of people’s experiences of and access to all mental health services to drive real improvement.
Action: The National Mental Health Commission will undertake a regular national survey of people with mental health difficulties and their families and support people. The survey will consider access to services, as well as perceptions and experiences. This will build on and complement existing efforts and ensure that people always have a voice and remain at the centre of decision-making about all the services that impact on them
2. Increase access to timely and appropriate mental health services and support from 6-8 per cent to 12 per cent of the Australian population.
Action: All governments must agree and meet the target proposed in the Fourth National Mental Health Plan Measurement Strategy that 12 per cent of the population should be able to access mental health services in a year.13 There must be agreement to this indicator with an implementation plan and investment strategy to achieve this.
3. Reduce the use of involuntary practices and work to eliminate seclusion and restraint.
Action: All jurisdictions must contribute to a national data collection to provide comparison across states and territories, with public reporting on all involuntary treatments, seclusions and restraints each year from 2013. This information should be reported at the service unit level.
Action: The National Mental Health Commission will call for evidence of best practice in reducing and eliminating seclusion and restraint and help identify good practice treatment approaches.
We will do this in partnership with the Mental Health Commission of Canada and Australian partners, including the Safety and Quality Partnerships Subcommittee, Disability Discrimination Commissioner, Australian Human Rights Commission and interested state mental health commissions.
4. All governments must set targets and work together to reduce early death and improve the physical health of people with mental illness.
The three big drivers of early death are suicide, cancer and heart disease.
Action: All jurisdictions must contribute to a national data collection to provide comparison across states and territories, with public reporting on all involuntary treatments, seclusions and restraints each year from 2013. This information should be reported at the service unit level. Enduring mental illness must be given the status of a chronic disease to give it higher national focus and support.
Action: The physical health needs of people with mental health problems need to be given a higher priority in all areas of health. The initial focus must be on rapidly reducing cardiovascular disease by reducing risk factors such as smoking, poor diet and by increasing physical activity for people living with mental health problems.
Action: All government funded mental health related programs must also be measured on how they support people to achieve better physical health and longer lives. Priority should be given to the financing of multi-disciplinary primary care (through GPs and other primary health care organisations).
Action: All relevant services must give priority to tracking both the physical and mental health needs of those with enduring mental illness.
5. Include the mental health of Aboriginal and Torres Strait Islander peoples in ‘Closing the Gap’ targets to reduce early deaths and improve wellbeing.
Action: Mental health must be includedas an additional target in the COAG ‘Closing the Gap’ program. This must be done through the development and implementation of an Aboriginal and Torres Strait Islander Mental and Social and Emotional Wellbeing Plan to commence in 2013. This must also address the current work and future findings of the Aboriginal and Torres Strait Islander Suicide Prevention Advisory Group.
Action: Training and employment of Aboriginal and Torres Strait Islander peoples in mental health services must increase. There must also be better support for Aboriginal and Torres Strait Islander families. There must be regular reporting on progress.
6. There must be the same national commitment to safety and quality of care for mental health services as there is for general health services.
Action: All governments must agree that there is the same emphasis on improving the quality of care and reducing adverse events in mental health services as applies to other physical health services. Governments must commit to implementing nationally agreed and mandatory service standards in mental health services as they have done for other health services. The National Mental Health Commission will work with the Australian Commission on Safety and Quality in Health Care (ACSQHC) to identify what it takes to get proper uptake of national mental health service standards and make them mandatory.
7. Invest in healthy families and communities to increase resilience and reduce the longer term need for crisis services.
Action: Increase enhanced and personalised support for parenting through culturally relevant forms of home-based visiting (ante-natal and in the first few years of life). These must be provided at a local or regional level. There must also be active follow-up where a family is under stress or experiencing tough financial or social difficulties.
8. Increase the levels of participation of people with mental health difficulties in employment in Australia to match best international levels.
Action: The National Mental Health Commission will pull together a Taskforce, including industry, government and community leaders to actively promote effective employment support programs and workplace based programs that increase the participation in employment of people with mental health difficulties.
The Commission will partner with the Business Council of Australia (BCA), Council of Small Business of Australia (COSBOA), the Mental Health Council of Australia (MHCA), Comcare and other key industry and community groups (including beyondblue and SANE Australia) to call for evidence and work together to advance the adoption of good workplace practices in Australia. This should support workforce leaders to change the way mental health is dealt with so that workplaces are more capable of dealing with mental health matters in a manner that leads to the betterment of the workforce and the workplace. The Commission will report progress.
Action: Employment support programs, initiatives and benefits must be more flexible. They must recognise that mental illness comes and goes and what that means for people and their families. Programs must provide long-term support for the employee, families and support people and the employer, with appropriate incentives and milestones.
9. No one should be discharged from hospitals, custodial care, mental health or drug and alcohol related treatment services into homelessness. Access to stable and safe places to live must increase.
Action: All governments must implement and report regularly on the existing COAG commitment of ‘no exits into homelessness’18 from statutory, custodial care and hospital, mental health and drug and alcohol services for those at risk of homelessness.
Action: Discharge planning must consider whether someone has a safe and stable place to live. Data must also be collected on housing status at point of discharge and reported on three months later, linked to the person’s discharge plan.
Action: Governments must commit to removing any structural discrimination barriers to people with mental health difficulties accessing social housing. Just as important is providing support to help vulnerable residents to settle in, adjust and remain in their homes.
10. Prevent and reduce suicides, and support those who attempt suicide through timely local responses and reporting.
Action: Programs with a proven track record (which are evidence-based) must be supported and implemented as a priority in regions and communities with the highest suicide or attempted suicide rates – action needs commitment and a humane approach.
Action: Develop local, integrated and more timely suicide and at-risk reporting and responses. These should be co- ordinated, community based, culturally appropriate, early response systems and suicide prevention programs. They should promote community safety, reach the most vulnerable, and use up-to-date information from the ‘first responders’ such as Police officers, occupational health workers, ambulance officers and mental health workers.
The report also highlights a lack of accountability
“It is not good enough when we know that as a nation we spent over $6.3 billion or $287 per Australian on mental health- related services in 2009-2010.
This expenditure has seen an average annual increase of 4.5 per cent of spending per Australian between 2005-06 and 2009-10.30 But there is little or no accountability as to what improvements we are getting for such a significant investment, whether it improves the health and wellbeing of people with a mental illness and provides them with the services.”
The report also says that increased access to psychological services under the Better Access and other initiatives have not addressed inequities, and that there are also unanswered questions about the effectiveness of services. It says:
“…increased access to services under these programs was not evenly shared across all communities. Under the Better Access program, people living in rural and remote areas had lower rates of access than those in cities. Young people also had lower rates of access… we start to see that services are growing, but not necessarily connecting with the people who need them most.
In short, we are currently unable to track if services are providing the right type of quality care and interventions – be it from a lived experience, family or government perspective – and whether these are making a difference.”
The Commission’s agenda for the future
Its forward work program includes:
• Undertaking a regular qualitative, whole-of-life survey that will capture the experiences of people with mental health difficulties and their families and supporters.
• Looking to governments to develop a set of national mental health performance indicators and targets that will tell an honest picture of how Australia is performing. If the Ten Year Roadmap for National Mental Health Reform doesn’t deliver, we will work with others to develop these
• Examining how Australians really think and feel about mental health, mental illness and suicide, including stigma and discrimination.
• With business leaders and other partners, calling for evidence on and working to advance good workplace practices. We will also take a broader look at the full impact of mental illness in Australia, on our work and the economy.
• Calling for evidence on the best international practice in reducing and eliminating the use of seclusion and restraint, in partnership with the Mental Health Commission of Canada and key Australian bodies
• Releasing a snapshot on how to engage young people in our work to ensure that they have a voice in our future Reports and the drive for improvement.
• Working with the Australian Commission on Safety and Quality in Health Care to look at what it takes to get the proper uptake of national mental health service standards and make them mandatory.
• Progressing mental health workforce issues commencing with a collaboration with Health Workforce Australia on the peer workforce.
• Providing policy input to the National Disability Insurance Scheme and Activity Based Funding
• Supporting the establishment of an International Knowledge Exchange to help in identifying and promoting evidence-based practice.
Speech Notes for Professor Allan Fels, Chair of the National Mental Health Commission
Australians are comfortable talking about a lot of things, but mental illness isn’t one of them.
However, learning from personal stories and experiences is essential to developing a new narrative, a new view of mental health in Australia.
I thank everyone who has given their time to speak with us this year about their lived experiences of mental health difficulties or their experiences supporting others.
Sharing personal stories takes immense courage.
I’d particularly like to acknowledge:
… Chris, Julie, Maddison, Kathleen, John, Kylie, Emma Leigh and Madeline, Greg, Elaine, Men, Carol, Carmel, Pat and Keith, Jasmine and Cindy
… whose stories are featured in our videos and this Report Card.
At the same time we can’t do enough justice to the overwhelming good work of people in support services and elsewhere, and the very positive initiatives that are happening across Australia every day.
We commissioners all felt a strong sense of responsibility while we developed the first of our Annual Report Cards, in our first year of operation.
Today over 7 million Australian adults have experienced a mental illness.
One in five Australians will experience a mental health difficulty in any given year.
Virtually every family has their own story but these personal stories are too often never heard.
For this reason, the Commission has placed people with a lived experience of mental health difficulties, as well as their families and supporters, at the core of all we do.
So when you read our report you’ll see that it’s different to the kind of report you might normally see because it goes far beyond the clinical and the medical. It looks at the whole life of those with mental health difficulties.
And the theme of our report card reflects a theme that came up again and again during our conversations with members of the community and our many stakeholders this year – A Contributing Life.
When we talk about a contributing life we mean a fulfilling life.
We mean a recognition that people living with mental health difficulties want and need the same things as everyone else, including a stable home, something meaningful to do, something to look forward to, strong connections to family, community and culture, and access to effective care, treatment and to services. To not be discriminated against. To have their rights acknowledged and acted on.
We have therefore written this report card for all Australians and we say:
We don’t care about political divides, and state divides.
We aren’t interested in buck passing, excuses, or even what’s been deemed to be acceptable.
We care about giving all in our Australian community a fair go.
We care about services, but more importantly, we care about people.
We especially care that right now, even when excellent services are being provided, they often are not wrapped in an approach that looks at the whole life of a person with mental health difficulties. Therefore they don’t necessarily offer people who experience a mental illness the best chance of recovery and a contributing life. And that includes their families.
I hope that we will all will look back on today as a special day
… when all Australian governments and communities recognised that mental health and suicide prevention are and must remain a high, national priority and found the courage to address some difficult truths.
In particular, here are some of the things that worried us that we believe must, and can be fixed:
We are shocked and saddened by the long-term high rates of physical illness and early death among people with mental health difficulties.
The statistics related to the physical health of these Australians are appalling.
Their health is worse than those in the general community on just about every measure.
Looking at people living with severe mental illnesses such as bi-polar disorder, schizophrenia or psychosis
… their life expectancy is reduced by 25 years on average because they face an increased likelihood of heart related conditions, diabetes and obesity.
We know that there are several reasons for the poor physical health of those with severe mental illness.
First, some antipsychotic medications prescribed to manage mental illnesses such as schizophrenia also contribute to the likelihood of developing chronic physical disorders.
…This is a difficult issue. But it is something that people living with mental health issues, families, supporters and community members raised with us again and again during the year.
Second, smoking, poor nutrition and physical diseases have a major bearing on physical health – and their incidence is high amongst people living with severe mental illness.
…Mental health difficulties too often overshadow chronic physical problems.
And health carers in either hospital or the community can underemphasise physical health problems when they see a person with a mental illness.
Third, suicide contributes to the worse death rate of those with severe mental illness.
Physical health and mental wellbeing are weaved intricately together and they need to be treated as such.
It highlights that mental health practitioners and GPs must work very closely together, and as part of a team with the person, and their family.
In relation to Aboriginal and Torres Strait Islander peoples, the Commission is also concerned that dealing with mental health problems is not currently included in national policy targets even though cardiovascular disease and mental illness are the two leading drivers for the burden of disease.
Another concern relates to the rates of involuntary commitment and treatments, which have remained stubbornly around 30 per cent, and the lack of public data around seclusion and restraint of people in care situations.
In 2005, all Australian governments agreed to reduce and where possible eliminate seclusion practices and treat people in care in the least restrictive way, but only four jurisdictions report seclusion rates publicly.
This is a very difficult and complex area and we don’t have all the answers
…but in the very least, the community must have the opportunity to see the data and contribute to the discussions on this issue. All governments must meet their legal obligations and existing commitment to ensure that involuntary treatments, seclusion and restraint of people in distress are minimised or eliminated.
And they must report publicly across all states and territories from 2013.
Other urgent actions include:
- stopping people from being discharged from mental health services into homelessness or unstable homes
- providing effective, local interventions to prevent suicide
- increasing access to mental health services from 6-8 to 12 % of Australia’s population
- and increasing access to home based visiting to support families and children.
The Australian community, service providers and all employers, have an important role to play too because Australia is not realising people’s potential.
We foresee real potential for improving the productivity of workplaces by supporting employers and employees alike to proactively increase participation rates of people living with a mental health condition.
This is an area where, with the willing support of business, we will do much more work next year.
These are just some of the issues we have raised in our report.
However, we had to make some very tough decisions on what we could cover in our first report this year.
We know that there are issues, problems and system gaps, and that many different groups of people, such as those from culturally and linguistically diverse backgrounds, veterans, refugees, people with intellectual disability and those living with borderline personality disorders and others face very real challenges.
Throughout the years ahead we will work on additional areas requiring a special focus such as these, as separate pieces of work.
This year we have also had to rely on existing data and statistics – much of which is incomplete or not particularly helpful.
For example, in 2009-10, we know that 1.7 million Australians (8% of our population) accessed public and private specialised mental health services.
Also, Australian taxpayers contributed $6.3 billion towards mental health service provision.
This is a significant investment. Yet there is little or no accountability as to whether these services improved the health and wellbeing of people with a mental illness, or provided them with the services they need.
In other words, we don’t know if they assisted people to move towards a contributing life.
Australia leads the world in progressive mental health policy, but it still falls down in delivery.
When the Commission was established this year attached to the Prime Minister’s portfolio, it kept mental health’s place at the top table, and the commitment to drive reform across all parts of government and the service system.
It also moved mental health out of the health sector and across each and every sector of a government’s portfolio and in every part of the community.
We believe that Australia can improve the lives of millions of Australians if the Prime Minister and State and Territory leaders find the courage to act tenaciously in their interests. We look to them to reaffirm their commitment to improve services and supports to that people have the opportunities to live contributing lives.
This will require continuing, strong bi-partisan support, and COAG’s leadership and commit to working collaboratively and swiftly to address the issues this world’s-first report has raised.
- reaffirming that mental health is a high national priority for all governments and the community
- agreeing on the right incentives to drive good services
- providing ‘a complete picture’ of what is happening and closely monitoring and evaluating change
- analysing the gaps and barriers to achieving a contributing life and putting a framework in place that sets Australia’s direction
This evidence and experience needs to demonstrate what represents good value for the taxes we pay.
And the real measure of success is whether services and support are being provided in ways that make a positive difference to vulnerable people’s lives.
This includes promoting inclusive approaches to supporting people with mental health difficulties
… which will include their families and support people as part of the one team, offers the best recovery pathways.
The Commission takes its role in holding Australian governments accountable extremely seriously.
We will be back with our second Report Card in 12 months’ time, reporting on what’s happened, whether people’s stories have changed and where things have improved.
I hope we’ll bring good news.
Reaction and further reading
• Next at Croakey: Sebastian Rosenberg’s report card on the report card – could do better next year…