Chapter 3: Facilitating access
A consistent message from people with lived experience of mental illness, and their carers and families is the difficulties that they have with accessing and navigating the mental health and suicide prevention system. Of particular concern are the many inconsistencies within the gateways and pathways to mental health treatment.
A range of possibilities have been proposed to assist with navigation and coordination to improve existing entry points, and to build additional consumer-preferred entry points to the mental health system.
Both Vision 2030 and the Productivity Commission have proposed a person-led system that responds to the needs of people seeking assistance, and allows people to choose how they interact with the system and the type of services that they need. Technology and the workforce have been identified as key enablers of a system that facilitates access and navigation regardless of whether a person enters the system through a general practitioner, the emergency department or other means.
Accessing and navigating the mental health system is also an issue for particular cohorts, including people living in rural and remote communities, and the older population.
This chapter discusses opportunities for facilitating affordable access to mental health services and treatment through innovation in digital mental health, addressing workforce issues, and strengthening the system response to rural and remote mental health. Emerging issues for rural and remote mental health and older people, including those accessing aged care services, are also discussed.
Digital mental health
Digital mental health services are offering new and innovative ways for people with lived experience, and their carers and families to access services. Digital services provide an opportunity to significantly increase access to care by transcending geographic, stigma, privacy and financial barriers. Specifically, there are opportunities for technology to be used across all levels of care, including:
- • provision of information
- • assessment and screening
- • online provision of self-guided programs and clinician-supported interventions
- • virtual general and specialist psychological interventions
- • connection and navigation of services
- • crisis supports
- • integration of self-directed interventions with clinician-led treatment approaches
- • provision of virtual tertiary consultation and coordination of virtual team care.
Research has found that:
- • digital mental health interventions in the workplace can improve employee psychological wellbeing and increase work effectiveness
- • digital mental health services enable effective outcomes for Aboriginal and Torres Strait Islander people, non-English speaking migrants, and older cohorts
- • digital mental health services create an access point for carers to receive training, establish social networks with other carers, learn from peer and expert advice, and engage in interactive problem solving.
Although there are clear benefits to the use of technology, there are also issues that need to be considered and addressed as digital mental health services expand. Concerns have been raised about accessibility to the internet and other digital technologies, and related considerations such as digital literacy—in particular, for people in regional and remote locations, and older Australians.
Lack of access to technology, devices and the internet, and low digital literacy can result in increased vulnerability for people who may have limited access to face-to-face options, or for those who may not have the technical skills to participate in the digital world or use health-related technology to its fullest potential. It is also important to understand and address the ways in which digital services integrate with face-to-face technology and how information is managed, including self-management by people with mental health concerns. In addition, we need to ensure that the evolution of digital technology does not exacerbate the deprivation of people experiencing poverty and inequality.
As highlighted in Sections 1 and 2, new technology is changing the way mental health services are delivered. With the introduction of new health technology tools such as wearables, apps and devices, connecting to and integrating mental health services is increasingly attractive and efficient. However, at present, awareness of the broad range of digital mental health services is not uniform among the mental health workforce, despite sites such as Head to Health that identify services suited to specific patient needs. Furthermore, for many clinicians, digital mental health services are limited to applications.
Continued research and evaluation are important to understand the effectiveness of digital mental health services, including specific services and modes of delivery, for the general population and different cohorts.
Online services need to be evidence based, and national coordination and oversight are needed to ensure that digital services are aimed at known gaps to minimise duplication, and ensure that the system remains consistent and accessible for people who need it.
The Commission recommends that a National e-Mental Health Strategy is developed after the National Digital Mental Health Framework is in place and mature, to help fill any gaps that may be found. Such a strategy will focus on the e-mental health ecosystem requirements for the use of digital platforms and applications, including examination of issues around privacy, ethics, artificial intelligence, predictive technologies, disruptive technologies, global reach and participation, and protection of risk.
Recommendation: The Commission recommends that the Australian Government develop a National e-Mental Health Strategy to complement the National Digital Mental Health Framework.
A theme throughout the Commission's Connections consultation in 2019 was that the current workforce does not have the capacity to deliver quality mental health services to the diverse communities in Australia and does not offer the breadth of services needed. This was attributed to a wide range of systemic issues, including inadequate training available for frontline workers, insufficient staffing levels, low retention of trained workers and lack of support for diversity in professional roles. The future challenge for the mental health workforce is to rethink its composition from what is traditionally considered a multidisciplinary mental health team comprising mental health professionals (such as psychiatrists, mental health nurses, social workers and psychologists).
Vision 2030 identifies a robust and multidisciplinary workforce as being a key performance enabler to implementing a successful mental health and wellbeing system. Such a system requires integration of services that address mental health, physical health and social needs.
A multidisciplinary workforce should extend beyond the clinical disciplines to appreciate the contributions from a wide range of professionals across all types of care in the stepped care model, from frontline prevention and identification through a range of treatments to recovery support and research. This workforce includes a wide range of clinicians (psychological, allied health, general practice and medical), recovery support workers, lived experience workers, counsellors, psychotherapists, frontline or emergency responders, and people working in community institutions more broadly, including sporting, cultural and religious organisations.
The Commission considers that the success of a multidisciplinary workforce depends on:
- • clearly identified roles and responsibilities that encourage professional recognition, with flexibility in scope, and a culture of collaborative practice and team approaches
- • recruitment and career pathways in mental health specialisation across all aspects of the workforce
- • appropriate mental health training, from primary qualifications to ongoing or specialised professional development and in-role training
- • retention of trained workers and incentives to take up mental health specialisations
- • resourcing to enable professions to work to their full scope of practice.
All jurisdictions in Australia have shown a commitment to the mental health peer/lived experience workforce, through either mental health plans and strategies, the development of peer workforce or lived experience frameworks, or standards and guidelines (see Appendix 6 for details).
Meaningful employment of designated lived experience roles is increasingly understood as contributing to best practice in service transformation, particularly in moving towards more recovery-oriented, person-directed service delivery. Lived experience contribution to the ongoing national reform agenda underpins the significance of the national peer/lived experience workforce. A well-supported lived experience workforce results in benefits for people accessing services, families, social networks, organisations and the broader community. The relationships made possible through lived experience work strengthen connection, resiliency, choice and hope, improving the lives of individuals and helping to transform services.
Following the completion of the National Mental Health Workforce Strategy (see Box 14), a critical next step will be developing an implementation plan to ensure that these improvements are realised. This will involve highlighting priority actions, and identifying measurable milestones and realistic time frames.
Recommendation: The Commission recommends that the Australian Government develop a National Mental Health Workforce Strategy Implementation Plan.
Box 14: National Mental Health Workforce Strategy 2020–2030
Due for completion by late 2021, the National Mental Health Workforce Strategy is being developed to consider the quality, supply, distribution and structure of the mental health workforce, and identify practical approaches for ensuring that the workforce can meet the demands of the mental health system over the next 10 years. A taskforce was established to oversee the development of the strategy. Some of the key mental health workforce challenges identified are the need to define the mental health workforce, diverse and changing population needs and consumer expectations, workforce shortages, rural and remote service provision, the need for the workforce to be responsive and flexible to changing circumstances, and measurement of progress. The strategy's five priority areas are:
- • attracting and retaining the mental health workforce for rural and remote areas, which requires consideration of structural, professional and personal factors
- • supporting and valuing Aboriginal and Torres Strait Islander leaders across the system
- • valuing and resourcing of the peer and lived experience workforce
- • training and education across the career journey
- • a whole-of-government approach to ensure that funding agreements and policy strategies relating to the workforce are interdependent and mutually reinforcing.
The strategy is undertaking data analyses to estimate the current workforce supply and compare this with workforce targets (demand) produced by the National Mental Health Service Planning Framework. It is also identifying data gaps for nonregistered mental health practitioners and how to address them. Additionally, the strategy is considering an analysis of capacity of educational institutions in the tertiary, vocational and community education sectors to respond to increased demand for mental health workers.
Rural and remote communities
Although the prevalence of mental illness in rural and remote areas is similar to that is metropolitan areas, people living in rural and remote areas face greater challenges in accessing appropriate support services. These difficulties are driven by the distribution of the mental health workforce, which is skewed towards urban areas.
One of the biggest issues in relation to the mental health workforce across professional streams and geographical areas is high staff turnover. Contributing factors include stress and burnout, an aging workforce, excessive workloads, insecure tenure, limited career paths, and reduced time for training, mentoring and supervision. Mental health professionals operating in rural and remote areas, and in private practice, may also experience isolation.
It is also important to recognise that the skill set required for the rural and remote mental health workforce often needs to allow workers to work across the primary, secondary and tertiary spectrum of care. Training packages that reflect this are crucial in supporting staff working outside major cities.
Digital technology can be useful for remote service provision and as an adjunct to the workforce in regional and remote areas, including as a method of providing distance education and training, and e-supervision to health professionals. However, digital mental health services should not be a substitute for face-to-face care unless that is what consumers want.
A range of opportunities exist to better meet the mental health needs of those living in regional and remote locations around Australia. Knowing the pivotal role that social connection and community participation play in wellbeing, programs that increase community connectedness and participation, build resilience and prevent mental distress should be prioritised. Such programs should be considered both in mental health services and more broadly, while acknowledging that each community has its own identity and culture. This embraces a holistic approach that acknowledges the key role of community and social connection as a preventive mental health measure.
Mental health initiatives under the Stronger Rural Health Strategy and the forthcoming National Mental Health Workforce Strategy will help to address key challenges, including strengthening the rural and regional mental health workforce, and improving availability of, and access to, mental health services. The aim of the Stronger Rural Health Strategy is to build a sustainable, high-quality health workforce that is distributed across the country according to community need, particularly in rural and remote communities. The strategy includes a range of incentives, targeted funding and bonding arrangements, and will give doctors more opportunities to train and practise in rural and remote Australia.
Recommendation: The Commission recommends that the Australian Government develop a National Regional and Remote Mental Health Strategy that looks holistically at the issues faced across diverse communities in regional and remote Australia.
The COVID-19 pandemic has highlighted the need to break down the siloed approach between aged care, hospitals, general practice, ambulance services and the whole health system, and develop cross-sector partnerships. The increasingly complex care needs of older people frequently require multidisciplinary services drawn from across the aged care and healthcare systems. The final report of the Royal Commission into Aged Care Quality and Safety (Aged Care Royal Commission) will include significant reforms to address the funding and jurisdictional boundaries and professional silos that negatively affect access to care and the care experience for the older person. It will also address the inequities of access between people in aged care facilities and older people in the community.
Reform in aged care should address the provision of care in its broadest sense, such as social and emotional health, psychological wellbeing, and biomedical and psychiatric considerations of a person's mental wellbeing.
The Commission's submission to the Aged Care Royal Commission recommends an approach based on implementing the Contributing Life Framework for older people. The approach needs to address current gaps in the mental health and aged care systems, and improve the overall wellbeing of older people, with the aim of reducing prevalence rates across the spectrum from mental distress to mental illness.
This holistic approach to care and planning includes delivery of mental health supports for older people, across the spectrum of care: promotion, prevention, crisis intervention, treatment and recovery.
It should also include greater interaction between aged care service providers and the wider service networks and community supports, addressing issues such as grief and loss, family relationships, loneliness and social isolation, AOD addictions, and spirituality.
Examples are expansion of programs, outside of clinical services, to contribute to the mental health and wellbeing of older people, such as 'befriending' programs, and a greater role for peer workers in both community and residential aged care settings. This would require further exploration of how the peer and lived experience workforce could contribute to mental health support, and act as a conduit between older people and mental health services.
Key reform areas for the interaction between the aged care and mental health systems include the following:
- • Improvement within the aged care system should include workforce capacity and training, enhanced data and reporting, and greater early access to specialist mental health care for older people.
- • Further national policy focused on improving older people's mental health and wellbeing in both aged care and mental health policy is needed.
- • A coordinated approach is required across the mental health and aged care sectors—that is, remove the silos.
- • Any new national aged care strategy, planning and funding framework, workforce strategy, regulation and monitoring processes should explicitly consider mental health, given the high rates of mental health issues among aged care residents.
There is currently no overarching approach to support the mental health of older people, which can be very different from the general population, due to declining health and frailty, bereavement, isolation and residential settings. There is a need to focus on promoting older people's mental health and ensure that mental health conditions are identified, and that coordinated support is provided early and in an accessible way.