Chapter 3: Current mental health and suicide prevention reform activities
As discussed in Chapter 2, how governments respond to the findings and recommendations of key inquiries will affect long-term systemic reforms of the mental health and suicide prevention system. In the meantime, initiatives to better meet the needs of consumers and carers continue to be implemented at national, state and territory, and regional levels.
Implementing the reform agenda requires collaborative leadership and cooperative planning. It also takes time, investment, commitment and flexibility to respond to barriers and emerging issues, and requires evaluation, monitoring and reporting on progress and outcomes to inform future planning and improvements.
A key theme identified in the Commission’s 2019 Connections tour to inform Vision 2030 was that the mental health system continues to present barriers to identifying needs and providing quality care that is accessible to all.
Consultation participants experienced disconnected and reactive services that did not cover the essential components of community-based care because of the split of responsibilities across governments.
Barriers to accessing the system were also raised by participants, who noted difficulties entering the appropriate level of care because services were not coordinated or were hard to navigate.
Also reported was a lack of consistency in services available across the spectrum of care, with different gaps experienced in different locations (including the gap in service provision between primary and acute services, commonly referred to as the ‘missing middle’). For example, often moderate-intensity care is accessible only when self-financed, or financed through private insurance or disability programs. This means that many people with a complex or chronic mental illness do not receive the full scope of care they need and cycle through the acute care system.
Results from the Commission’s Consumer and Carer survey (Box 6) offers similar insights to those highlighted in the Connections project. The Consumer and Carer survey is conducted annually to inform the Commission’s reporting on the progress of the Fifth Plan.
Box 6: Consumer and Carer survey
The Commission has extended its Fifth Plan reporting by including an annual survey of mental health consumer and carer perspectives. The survey aims to measure whether consumers and carers are experiencing the improvements and benefits outlined in the ‘what will be different for consumers and carers’ section of the eight Fifth Plan priority areas.
The results from the 2020 Consumer and Carer survey suggest the following:
- • The intended benefits from improving integrated regional planning and service delivery have not yet been realised for a significant proportion of consumers and carers.
- • Most consumers and carers are aware of support services available to those at risk of suicide, but fewer people are aware of active follow-up care for people who have attempted suicide or services that are available for carers, families and communities affected by suicide.
- • Many consumers with severe and complex mental illness do not have access to the clinical and nonclinical community-based services required to live a contributing life.
- • Coordination of physical and mental health care continues to be limited.
- • Stigma and discrimination remain common for people with mental illness, both in healthcare settings and in the broader community.
- • Although mental health services are a safe place for the majority of people, a significant proportion of respondents do not consistently feel safe using these services.
- • Most consumers and carers have not observed improvements in mental health services and have not been invited to contribute to service improvement.
Collaborative partnerships in system reform
To effectively address mental health and suicide prevention in Australia, a national approach is required to improve strategic oversight and coordination of mental health policy and investment.
The National Mental Health Strategy is the policy framework, introduced nearly 30 years ago, that guides mental health reform for all governments to work together to change a system that has been widely acknowledged as inadequate and long neglected by policy makers.
A complex web of strategies, plans and frameworks representing national, and state and territory priorities has been developed and implemented (at times only partially).
The Fifth Plan is the main instrument that sets out the current national reform agenda for mental health and suicide prevention in Australia from 2017 to 2022. State and territory plans align with the national plan, but reflect their own priorities. The approach to how consumers and carers, the community sector and private providers are engaged is not consistent. The Fifth Plan was agreed by all governments, and was accompanied by an implementation plan with actions, responsibilities and time frames. For the first time, the National Mental Health Plan included annual public monitoring and reporting. Some limited national projects received funding from the Council of Australian Governments under the Fifth Plan, but most activity was unfunded.
Under the Fifth Plan, a number of key national activities have been progressing, including initiatives led by the Commission, such as the National Mental Health Research Strategy and the National Lived Experience (Peer) Workforce Development Guidelines (see Box 7). Additionally, under the Long Term National Health Plan announced in 2019, reform initiatives such as Vision 2030, the Primary Health Care 10 Year Plan, the National Preventative Health Strategy and the Medical Research Future Fund investment plan have been progressing.
Box 7: National Lived Experience (Peer) Workforce Development Guidelines
Under the Fifth Plan, the Commission is leading the development of the National Lived Experience (Peer) Workforce Development Guidelines by 2021. The guidelines support ongoing development of the lived experience workforce in Australia, providing a roadmap for organisational and sector leaders across diverse settings to inform the development of governance, policies and practices that support sustainable and effective growth.
This work aligns with recommendations from the Productivity Commission inquiry into mental health and the Royal Commission into Victoria’s Mental Health System to grow and enhance workplace supports for the peer and lived experience workforce. The guidelines will provide guidance for governments and employers on the knowledge and supports required to grow the workforce in a sustainable and effective manner. Although some local and regional frameworks for the peer and lived experience workforce exist, the development of national guidelines aims to foster consistency across Australia.
The Productivity Commission considers that the National Mental Health Strategy does not meet consumer and carer expectations and should be strengthened by facilitating a genuine whole‑of‑government approach, linking funding with the strategy, setting a clearer vision, ensuring greater coherence, and widening stakeholder engagement.
To achieve this, the Productivity Commission has recommended a new national strategy between the Australian Government and state and territory governments that comprehensively integrates the roles played by health and non-health sectors, and guides the efficient allocation of funds and resources.
In line with this, Vision 2030 addresses these concerns by prioritising governance structures that are clearly defined and implementable through formal agreements between the Australian Government and state and territory governments in a way that is transparent, consistent and measurable.
In October 2020, National Cabinet announced a new Mental Health National Cabinet Reform Committee to deliver a new National Mental Health and Suicide Prevention Agreement by November 2021 and to oversee, and provide advice to National Cabinet on, implementation of the National Mental Health and Wellbeing Pandemic Response Plan. The Commission supports this kind of national collaboration and continued focus on addressing long-term recovery from the mental health impacts of the COVID-19 pandemic. The development of a new National Mental Health and Suicide Prevention Agreement also provides an opportunity to improve our national approach and supporting governance structures, particularly if related recommendations from the Productivity Commission's inquiry into mental health are taken on board. The interim advice from the Prime Minister's Suicide Prevention Adviser also supports whole-of-government leadership and governance.
New ways of working have started to impact on governments. Of particular significance is the new National Agreement on Closing the Gap that involved all levels of government and representation of the peak Aboriginal and Torres Strait Islander organisations. For the first time, the National Agreement on Closing the Gap includes a target aimed at reducing Aboriginal and Torres Strait Islander suicide rates, in addition to the inclusion of social and emotional wellbeing as a priority area. Other priority areas include justice, housing, early childhood care and development, and Aboriginal and Torres Strait Islander languages.
Prioritising lived experience in system reform
The Productivity Commission and the Royal Commission into Victoria’s Mental Health System both recognised that a well-informed, functioning mental health system that adequately meets the needs of consumers and carers is achievable only with the inclusion of lived experience.
Beyond inclusion, mental health reform needs to place those with lived experience at the centre, as the driving influence for change and system improvements.
Engaging effectively with consumers and carers requires a new way of working that recognises the value of lived experience perspectives, and acknowledges consumers and carers as equal partners.
Lived experience groups and organisations currently contribute to mental health reform in various ways through systemic advocacy, and working to embed consumer and carer interests and voices. For example, the National PHN Mental Health Lived Experience Engagement Network (MHLEEN) was established in 2018 to share approaches around lived experience engagement and co-design. Since then, MHLEEN has increased the participation of people with lived experience in the development of new PHN programs, increased the number of PHNs employing or engaging consultants with lived experience, and conducted a stocktake of engagement and participation opportunities within PHNs across Australia.
Mental health services must be designed, planned and evaluated via partnerships between the consumers and carers who use the service and service leaders.
The Mental health safety and quality engagement guide, a Fifth Plan action the Commission was responsible for, aims to empower and support mental health consumers and carers, and health service leaders to engage in meaningful partnerships to improve safety and quality in mental health services. The guide specifically focuses on participation by consumers and carers at a governance level. It recognises the importance of people with lived experience influencing strategic decision making and in promoting systemic changes in all aspects of mental health services.
Another co-design model is the development of the Reimagine Today website managed by the Mental Health Coordinating Council of New South Wales and partially funded by the NDIA. Reimagine Today provides information and resources to assist with understanding NDIS psychosocial disability provisions, and provides clear and practical advice on how to access the NDIS. The website was co-designed with and for people living with mental health conditions and their supporters. This model provides a sound example of an effective co-design process leading mental health reform, which can be applied more broadly across other initiatives.
Another significant initiative is the Aboriginal and Torres Strait Islander Lived Experience Centre, which was established in 2020 as the culmination of the Indigenous Lived Experience Project in 2018, led by the Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention and supported by the Black Dog Institute. The centre aims to embed the expertise of Aboriginal and Torres Strait Islander people with lived experience in mental health and suicide prevention initiatives across the country. It will foster the support, connections and learnings required to establish and enable an Indigenous-led National Lived Experience Network.
In April 2020, the Australian Government launched the new Carer Gateway to provide a single entry point for carers seeking information on, support for and/or referral to mental health services. The Commission encourages co-designed evaluation of the new gateway to establish how effective it is and inform improvements, where required.
Eliminating stigma and discrimination
Eliminating stigma and discrimination is essential if all Australians who experience mental ill-health, trauma or distress are to access care and support, and participate fully in the life of their community.
Increasing knowledge and understanding of mental ill-health can encourage those who may be struggling with their mental health to seek help, to know how and where to seek help, and to find out what services might be helpful for them. At the same time, it begins to break down the self-stigma that those experiencing mental ill-health may face. Shame and the fear of being stigmatised or discriminated against by others can act as a barrier to seeking help and support.
Research shows that, although attitudes towards people living with anxiety and depression have improved over the past two decades, attitudes towards those living with complex mental health issues such as schizophrenia are less favourable. Findings from SANE Australia’s National Stigma Report Card, released in October 2020, have indicated that experiences of stigma and discrimination continue to be pervasive in Australia for people with complex mental health issues.
The ‘Our Turn to Speak’ survey identified that interpersonal relationships, employment, healthcare services, social media and mental health care services were the areas in which people were most affected by stigma and discrimination. However, stigma and discrimination were not limited to these domains.
These findings indicate that stigma and discrimination remain entrenched in our society and culture, experienced in the close personal relationships we form, and in the mass media and social media that surround us.
They are institutionalised in the services we access to seek help for our mental health and the broader institutions we interact with in our daily lives. Notably, these broader institutions often seek to address factors that are essential for good mental health and wellbeing, such as safe and secure housing or economic security.
In the Commission’s Spotlight report on complex trauma (due for release in 2021), focus groups with people who had experienced complex trauma reported facing significant levels of stigma.
Often, stigma and discrimination were perpetrated by those within the system, including nurses, doctors and police. The profound impact these experiences can have on a person’s sense of self-worth and on their recovery journey cannot be overstated.
Under Priority Area 6 (Reducing stigma and discrimination) of the Fifth Plan, governments are required to take action to reduce stigma and discrimination experienced by people living with mental illness, with a focus on reducing stigma and discrimination in the health workforce. Stigma in a workplace is generally the result of discriminatory and/or prejudicial beliefs, attitudes and assumptions.
Stigma is embedded in our society and institutions, and the language we use to talk about mental health can reinforce stigma. Therefore, encouraging safe and appropriate language when discussing mental health and suicide can work to reduce stigma and discrimination. The Life in Mind project, led and developed by Everymind, published a National Communications Charter in 2018 that is designed to guide the way we talk about mental health, social and emotional wellbeing, mental ill-health and suicide prevention, with each other and the community. Organisations and individuals are asked to make a formal commitment to work together, and develop better structures and processes for collaboration.
The Commission has recently been tasked with developing a National Stigma and Discrimination Reduction Strategy, as recommended in the Productivity Commission’s final report. This strategy will build on the work started under the Fifth Plan, and will be co-designed with people who are affected by mental ill-health, trauma or distress.
The strategy will outline a long-term vision for a society where all Australians can live long and contributing lives, free from stigma and discrimination. The strategy will also articulate clear priorities, focus areas, objectives and actions over four years to:
- • eliminate structural stigma and discrimination in identified settings
- • reduce public stigma by changing attitudes and behaviours in the general community and among identified target audiences
- • reduce self-stigma among those who experience mental ill-health, trauma and distress, and those who support them.
Facilitating access to, and delivery of mental health care
Increase equity of access to services, innovative and flexible approaches to service delivery are required. It is essential that new models of treatment, care and support are developed that are affordable, culturally appropriate, timely and available regardless of where a person lives.
Accessing mental health care can often be more difficult for certain groups of people who face unique geographic, social, cultural and economic barriers, including those in rural and remote regions, Aboriginal and Torres Strait Islander people, people from culturally and linguistically diverse backgrounds, and older people.
The role of digital mental health
Digital technologies are increasingly being used to break down various access barriers and provide effective treatment, care and support to consumers. Digital services have been key in ensuring the continuation of mental health service delivery in the absence of face-to-face supports during the COVID-19 pandemic. Digital technologies and online services can also benefit the rural and regional mental health workforce by facilitating multidisciplinary treatment when workers are in different locations, and delivering education and training.
In October 2017, the Australian Government launched Head to Health, a digital mental health gateway website. For ease of access in a single location, the website lists digital mental health services and resources, including a range of free or low-cost apps, online support communities, online courses and phone services. As at October 2020, more than 2,035,318 online sessions (people accessing the online resources) had taken place through the website, averaging approximately 1,855 sessions per day.
The website provides a useful resource for health practitioners by increasing accessibility to evidence-based mental health supports, particularly in rural areas. However, research has highlighted issues around the integration of digital mental health services into clinical practice, recommending the development of integration guidelines to provide clarity.
Although digital services offer an innovative solution to address the digital divide and equitable access to mental health care, it is a relatively new approach. They require a coordinated, consistent approach to ensure safety and quality, and tighter guidance around best practice for service providers and developers.
The Australian Commission on Safety and Quality in Health Care is developing the National Safety and Quality Digital Mental Health Standards to address these concerns. Consultations with consumers, carers, providers and technical experts were conducted in early 2020, and the standards were released on 30 November 2020.
In addition, under the Fifth Plan, development of the National Digital Mental Health Framework is currently underway. The framework aims to provide an integrated and strategic approach to digital mental health service delivery within the broader context of Australia’s mental health system. This includes defining optimal delivery of digital mental health services to improve service access (including workforce considerations), reduce duplication of effort and investment, and embed digital mental health services in the broader mental health service system.
The role of Primary Health Networks in mental health care
The Commission has previously monitored the establishment of PHNs as a core component of mental health system reform. As PHNs become increasingly responsible for commissioning a range of services, the focus is now on the role of PHNs in working with LHNs to provide integrated regional plans for service delivery, and as regional bodies in coordinating services to improve access to, and delivery of mental health care.
Adult Mental Health Centres
In May 2019, the Australian Government committed $114.5 million over five years to trial one Adult Mental Health Centre in each state and territory.
The centres will complement existing services in the community setting, especially state and territory services. Lessons will be learned from the joint work in developing the HeadtoHelp hubs by the Australian Government and the Victorian Government (discussed in Section 2).
Given the significant investment in this initiative, it is important to evaluate it to inform any future rollout of these centres, and ensure that they are effective in complementing existing community mental health services. Equally important is ensuring that evaluation outcomes are made publicly available to inform future policy and service delivery initiatives. Mental Health Australia's response to the proposed service model has suggested that evaluation processes should report on the degree of local co-design and the relationship between this and service outcomes.
The mental health sector's response during the consultation phase for the proposed model has largely been positive. However, lack of clarity in how the centres will integrate or interact with existing community mental health services has been raised. Building on PHN-LHN local mapping to identify the specific role of each centre in its local area has been suggested as a way of ensuring that the centres are tailored to meet local needs and to avoid duplication of existing local services. Other issues are tensions associated with balancing national consistency with local and regional tailoring, and potential equity issues for rural and remote areas due to existing workforce shortages. Management of these issues will require strong national governance and direction. Further, understanding the complexities of supporting people in crisis will be crucial to the success of the model.
Community-based residential eating disorder treatment centres
In April 2019, the Australian Government announced the establishment of six new community-based residential treatment centres for people with eating disorders across Australia. This is in addition to funding previously provided for the Wandi Nerida residential eating disorder centre in Queensland. Establishment of the centres is currently underway in each jurisdiction. The centres are intended to provide wraparound support and specialist care through delivery of evidence-based treatment programs.
The centres will be well placed to provide tailored access and support for people with eating disorders, by providing a safe and healing environment for those most in need of psychological and physical care. This also be an important pilot project to inform future treatment models for eating disorders in Australia.
Three PHNs have participated in Link-me, a large-scale trial of a new approach to stepped mental health care in general practice, particularly for those with complex needs. A final report has been delivered to the Australian Government that considers whether the use of a purpose-built decision support tool (DST) leads to clinical, cost-effective benefits relative to usual care. The DST is built to systematically identify, and provide tailored treatment recommendations to, people with low and high levels of mental health needs.
The Productivity Commission’s findings have suggested that the DST can improve the assessment and referral practices of general practitioners (GPs) by identifying the mental health needs of people going to the GP. The Productivity Commission also proposed that the extent of benefits resulting from the tool, clinical benefits and cost savings, should inform governments commissioning activities in line with the stepped care model.
Use of the DST is significant in relation to navigation of the system because it has the potential to improve GPs’ abilities to provide appropriate mental health referral pathways at the appropriate level of care. This could provide a smoother path through the mental health system for consumers and their carers.
Psychosocial disability and the National Disability Insurance Scheme
Various concerns have been noted about access to the NDIS for people with psychosocial disability and access to appropriate mental health supports for people who are not eligible for the NDIS. These concerns were raised in the Commission’s National Report 2019, and efforts to address them have been progressing. The NDIA has provided clearer guidance on the evidence required by people with psychosocial disability to access the NDIS. Additionally, the role of the Partners in the Community program has been enhanced to include outreach activities to increase access to the NDIS for people with psychosocial disability. New NDIS Psychosocial Disability Community Connectors have now commenced in seven regions across Australia.
In June and December 2019, the NDIA released reports on participants with psychosocial disability. These provided detailed information about plan funding, numbers of participants, client funding, satisfaction and outcomes. The NDIA has also released quarterly reports that provide national and state-based data on participants in the NDIS, including figures on new participants with psychosocial disability.
The Australian Government has also implemented three programs to assist with the transition of people from a number of Australian Government–funded mental health programs that are ceasing as a result of transfer of funding to the NDIS. These are the Continuity of Support measure, the National Psychosocial Support Transition measure (NPS-T) and the National Psychosocial Support measure (NPS-M). On 29 March 2020, the Australian Government announced that it would invest a further $28.4 million to extend support for the remaining clients of the NPS-T until 30 June 2021. An evaluation of the Continuity of Support measure and the Australian Government component of the NPS-M commenced in March and will be completed in early 2021. While the number of people on these programs has decreased significantly (from 15,484 at 1 July 2019 to 1,854 remaining clients at 30 September 2020) - concern continues about which ongoing services will be available for people who are found to be ineligible for the NDIS.
The Council of Australian Governments Disability Reform Council announced on 9 October 2019 a number of initiatives to improve access and experiences for participants with psychosocial disability. Key initiatives include:
- • undertaking a joint examination of access and eligibility
- • improving linkages and referrals to mental health supports for people not eligible for the NDIS
- • assertive outreach to increase access to the NDIS for people with psychosocial disability
- • a psychosocial disability recovery approach
- • a national approach to concurrent supports.
The implementation of the recovery coach role has been welcomed by the sector. This involves choice of a recovery coach with lived experience, to help in coordinating and navigating the NDIS, including planning, reviewing and getting the services needed for recovery. There has been some criticism of the pricing of these roles and confusion around how the role is an improvement on the support coordinator role.
Evidence provided to the Joint Standing Committee on the NDIS, outlined in a report released in December 2020, notes that, despite recent improvements to the NDIS, people with psychosocial disability continue to experience challenges accessing the scheme and obtaining supports.
The report recommends that the NDIA “regularly and systemically engage with people with psychosocial disability and representative organisations to better understand the needs of people with psychosocial disability and mental illness”.
The report also outlines concerns raised in submissions to the committee about the new independent assessments process to access the NDIS that is due to be introduced later in 2021. The independent assessor was introduced to address concerns about inconsistencies in assessments of a person’s functional capacity. Concerns raised in the report included that the assessments would create stress and trauma for people with disability, do not provide understanding of a person’s support needs without their own specialists’ involvement, and are being implemented without effective consultation.60 The NDIA intends to consult further on how assessments will operate over the coming months. The Joint Standing Committee on the NDIS launched an inquiry in December 2020 into the independent assessments.61 The Commission will monitor the outcomes of this inquiry.
Integrating mental health and substance use services
The use of alcohol and other drugs (AODs) can interact with mental health in ways that create serious adverse effects on many areas of functioning, including work, relationships, health and safety. Comorbidity—that is, the co-occurrence of an alcohol, tobacco or other drug use disorder with one or more mental health conditions—complicates treatment and services for both conditions. These conditions can also co-occur with physical health conditions (for example, cirrhosis, hepatitis, heart disease, diabetes), intellectual and learning disabilities, cognitive impairment, and chronic pain.
Given the strong relationship between mental health and alcohol, tobacco and other drugs, it is imperative to improve collaboration and coordination between services. Clinicians can struggle to differentiate symptoms, resulting in misdiagnosis and delays in treatment. Many people with comorbidities have to seek support from separate mental health and AOD services, adding an additional layer of complexity when navigating the service system.
The National Drug Strategy 2017–2026 is the national framework for preventing and minimising alcohol, tobacco and other drug–related health, social and economic harm to individuals, families and communities.
The strategy advises that collaboration and coordination between mental health and AOD services needs to be improved to ensure that the most appropriate treatment and support are being made available to the individual.
The integration of mental health and AOD services has been on the reform agenda for some time in Australia. Historically, there have been significant problems with management of people with comorbidity, partly due to a lack of specialist services, particularly for AOD treatment. However, even where specialist mental health and AOD services are available, they are usually separated physically, administratively and philosophically. A 2006 Senate inquiry into mental health found that the separation of mental health and AOD administrations made operational coordination of services difficult. The inquiry also found that these difficulties were consistently raised as one of the greatest service limitations for consumers.
The role of PHNs in commissioning AOD treatment services at the local level complements their role in coordinating Australian Government–funded mental health programs, as well as building linkages with primary care. The Fifth Plan recognises the importance of jointly considering substance use comorbidities in system and service planning at a regional level. Through the Fifth Plan requirement for PHNs to undertake joint regional planning with LHNs and Aboriginal Community Controlled Health Organisations, PHNs are in a good position to influence the integration of AOD, mental health and primary care services. Some PHNs are already developing integrated regional plans—for example, the North Western Melbourne PHN region’s Blueprint for Better Health (integrating mental health, AOD and suicide prevention services) and the Brisbane South PHN region’s Mental Health, Suicide Prevention and Alcohol and Other Drug Foundation Plan 2020–2022.
Multicultural mental health
At the national level, attention to multicultural mental health in Australia has been lacking. No national prevalence data on mental illness in migrant and refugee populations in Australia is collected. Further, an absence of key culturally and linguistically diverse variables in existing data collections means that there is a clear need for the mental health sector to actively do more in this space.
In its 2014 Contributing Lives review, the Commission recommended the widespread adoption of the Framework for Mental Health in Multicultural Australia: Towards Culturally Inclusive Service Delivery as a tool to help organisations identify what they can do to improve their cultural responsiveness. Adoption of the framework has also been supported by other organisations, such as the Queensland Mental Health Commission and the PHN Advisory Panel on Mental Health. Redeveloped in collaboration with Mental Health Australia, the Federation of Ethnic Communities’ Councils of Australia and the National Ethnic Disability Alliance, and funded by the Australian Government Department of Health, the framework has the potential to improve mental health service delivery for people from culturally and linguistically diverse backgrounds on a broad scale.
Through the framework, organisations and individual practitioners are able to evaluate and improve the cultural responsiveness of their services using self-assessment against cultural competency standards, and accessing guidance and supporting resources.
Online modules and self-reflection tools that are self-paced, and guide ongoing and sustainable action are also incorporated into the framework. The framework guides a comprehensive quality improvement process by identifying where improvements are required, and how to implement and assess them.
By increasing the cultural responsiveness of services on a wide scale, the framework is working to address the lack of access to mental health services and information often faced by culturally and linguistically diverse communities. The Commission recommends continued support for further widespread uptake of the framework. Specifically, a mandatory requirement (or contracted obligation, where applicable) for adoption of the framework would assist widespread uptake. Adoption of the framework should be the minimum requirement for an organisation to meet the mental health needs of people from culturally and linguistically diverse backgrounds.
Organisations and mental health services should strive to embed cultural inclusivity and responsiveness into their services in a manner that suits their particular contexts. This should be done through co-design of services with people from culturally and linguistically diverse backgrounds with lived experience of mental health challenges.
Improving the physical health of people with mental illness
The Commission’s National Report 2019 noted evidence that the life expectancy gap is widening for people with severe mental illness, and that people across the continuum of severity of mental illness are experiencing poorer physical health outcomes than the general population.
In 2017–18, 58% of people with mental illness also had a long-term physical health condition, compared with 37% of people without mental illness. These physical conditions include asthma, arthritis, cancer, diseases of the circulatory system, diabetes, back problems and chronic obstructive pulmonary disease.
In 2017, the Commission launched Equally Well, the National Consensus Statement on improving the physical health and wellbeing of people living with mental illness. All jurisdictions committed to implementing Equally Well and embedded this commitment in the Fifth Plan, which identifies improving the physical health of people living with mental illness and reducing early mortality as a priority area. PHNs and LHNs are jointly working on regional planning and coordination activities to address this priority area.
More than 50 organisations pledged their support to Equally Well for improving the physical health of people living with mental illness in Australia when it was launched in July 2017. This included all state and territory governments, professional colleges and associations, consumer and carer organisations, community organisations and peak organisations, all mental health commissions, and 14 PHNs. An additional 40 organisations have since committed their support.
Equally Well aims to bridge the life expectancy gap between people with mental illness and the general population, and improve the quality of life of people with mental illness by providing equal access to health care.
It includes 48 actions aimed at delivering person‑centred, effective, equitable and coordinated health care. Equally Well aims to reduce variation in care, address the often siloed approach to treatment and care, improve service effectiveness and efficiency, and improve health outcomes for people living with mental illness and their families and carers. The Equally Well website provides a range of resources to help with improving physical health and highlight the importance of keeping healthy.
The Commission monitors and reports on the implementation of the National Consensus Statement by all governments through the annual Fifth Plan Progress Report. The 2020 Fifth Plan Progress Report will report on the progress of the National Consensus Statement between 1 July 2019 and 30 June 2020.
Implementation of Equally Well has the potential to lead to significant improvement at the primary healthcare–acute care interface. The Productivity Commission’s final report has acknowledged the potential of Equally Well by recommending that all governments implement all its actions and release clear statements on how they intend to implement the initiatives, including time frames and outcomes against which progress can be measured.
Medicare Benefits Schedule Review
The MBS Review was established in 2015 to consider how more than 5,700 items on the MBS can be better aligned with contemporary clinical evidence and practice, to improve health outcomes for patients. Various specialised committees, reference groups and working groups have been established as part of this review to consider and advise on MBS items. These include a reference group on MBS items for primary mental health care, and another for psychiatrists to advise on all mental health–related MBS aspects. The MBS Review Taskforce has recently finalised its recommendations regarding mental health–related MBS items, and the Australian Government is currently considering its response.
The Australian Government’s response to the recommendations in the review has the potential to transform existing measures within the MBS, such as the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative; a stepped care approach to MBS mental health services; increased flexibility of MBS mental health services; and incorporation of the latest evidence. The Commission looks forward to the release of the Australian Government’s response so that these improvements can be implemented.
Suicide has a significant impact on families, communities and society, prompting multiple governments to commit themselves to specific reduction targets—some towards a target of zero suicides. Australia’s suicide rate has increased over the past 10 years. In 2019, 3,318 people died by suicide in Australia, making it the 13th leading cause of death. In 2019–20, multiple government and nongovernment suicide prevention reform activities were underway.
These included the work of the National Suicide Prevention Adviser and Taskforce (see Box 8), development of the National Suicide and Self-harm Monitoring System, implementation of the National Suicide Prevention Trial sites, and establishment of a National Commissioner for Defence and Veteran Suicide Prevention.
The National Suicide and Self-harm Monitoring System (see Box 5) consolidates the suicide evidence base by bringing together existing data, as well as a range of new data from across states and territories, on a publicly available website. This information will help governments, service commissioners and the community to better understand the burden and impact of suicide risk, suicidal behaviours and self-harm. It will play a key national role in better informing public conversations about suicide prevention.
Twelve National Suicide Prevention Trial sites have been implemented across Australia, using various models. In addition, there are 12 local area suicide prevention trials in Victoria, four Black Dog Institute LifeSpan trials in New South Wales and one Black Dog Institute LifeSpan trial in the Australian Capital Territory. These trials have different time frames, but the combined results will provide valuable information about the various approaches to suicide reduction. The past 12 months have also seen investment in suicide prevention research and suicide prevention projects reflecting all governments’ commitment to preventing and reducing suicides. See Appendix 4 for further details of suicide prevention activities.
The establishment of a National Commissioner for Defence and Veteran Suicide Prevention in 2020 to look into suicides of veterans and serving Australian Defence Force members (see Chapter 1), and the completion of the Productivity Commission inquiry into compensation and rehabilitation for veterans were welcomed. The Australian Government responded to the Productivity Commission’s inquiry recommendations made in the final report A better way to support veterans by releasing the new Veteran Mental Health and Wellbeing Strategy in May 2020, and the Veteran Mental Health and Wellbeing National Action Plan 2020–2023 in August 2020. Although the role of the Commissioner has been welcomed, there have been calls for a Royal Commission to investigate veteran suicides.
There has been a renewed focus on Aboriginal and Torres Strait Islander participation, partnership and leadership in preventing and reducing suicide. The new National Agreement on Closing the Gap (see ‘Collaborative partnerships in system reform’, above) includes for the first time a target to reduce Indigenous suicides.
Gayaa Dhuwi (Proud Spirit) Australia was established in March 2020 as the national leadership body for Aboriginal and Torres Strait Islander social and emotional wellbeing, mental health and suicide prevention. It is governed and controlled by Indigenous experts and peak bodies working in these areas, promoting collective excellence in mental health care. Gayaa Dhuwi (Proud Spirit) Australia has started renewing the 2013 National Aboriginal and Torres Strait Islander Suicide Prevention Strategy, in consultation with stakeholders and community members, which aligns with recommendations from the Commission’s National Report 2019.
A number of states and territories have increased investment in suicide prevention approaches (details on state and territory initiatives are provided in Appendix 4). For example, the New South Wales Government has identified suicide prevention as a Premier’s Priority with the Towards Zero Suicides initiatives, as part of the Strategic Framework for Suicide Prevention in New South Wales 2018–2023. Victoria has introduced the Hospital Outreach Post-suicidal Engagement (HOPE) initiative, which provides enhanced engagement and support for people leaving the emergency department or medical ward following treatment for a suicide attempt.
Nongovernment organisations have been taking an active role in 2020, especially in addressing the impacts of COVID-19 and the bushfires (activities related to the bushfires and COVID-19 are outlined in Section 2 and Appendix 3). For example, the Suicide Prevention Research Fund has provided funding to support Australian research in suicide prevention and identify gaps in current research. The fund aims to support world-class Australian research, and facilitate the rapid translation of knowledge into more effective services for individuals, families and communities. The fund is managed by Suicide Prevention Australia, with Australian Government funding provided for three years. Suicide Prevention Australia also released the State of the Nation in Suicide Prevention: a Survey of the Suicide Prevention Sector Report, which provides valuable insights from the suicide prevention sector. In particular, it examines the impact of COVID-19 on an already strained mental health sector, with 78% of organisations surveyed experiencing an increase in demand, and 65% needing greater funding and support to cope.
The Black Dog Institute’s white paper, released in October 2020, explores existing data that relates to suicide prevention and how it can assist with prevention initiatives. Roses in the Ocean has been working with workplaces to develop greater awareness of how an organisation’s culture can respond and support staff who are experiencing the impacts of suicide. Drawing from these experiences allows workplaces to develop better practices, and provide input into suicide prevention and postvention initiatives.
Suicide prevention initiatives currently being undertaken in Australia may have a significant impact on the future direction of planning and investment for suicide prevention. Ongoing monitoring of these initiatives will be important to determine how well proposed initiatives are taken up and whether they are effective in reducing Australia’s suicide rate.
Box 8: National Suicide Prevention Taskforce update
To support the work of the National Suicide Prevention Adviser (the Adviser), a National Suicide Prevention Taskforce was established in August 2019 in the Australian Government Department of Health. Joint governance is provided by the Australian Government Department of the Prime Minister and Cabinet.
The Adviser reported directly to the Prime Minister on the effectiveness of design, coordination and delivery of suicide prevention activities.
In November 2019, the Adviser provided the Prime Minister with initial findings and some emerging advice to inform and complement the Australian Government’s Towards Zero Suicides initiatives. The initial advice outlined the need for a fundamental shift to a broader approach that places the needs of people at the centre of all strategies and initiatives.
The interim advice was publicly released in November 2020. It focused on the key actions required and made recommendations about how a whole-of-government approach can be best implemented within Australia’s system of governments, highlighting the proposed enabling structures and strategic approach needed. The interim advice emphasises the importance of incorporating understanding of suicidal behaviour from those with a lived experience of suicide. It was accompanied by the Compassion first report, which drew together the perspectives of people with a lived experience of suicidal distress and suicide attempts. The advice highlighted the need for broader government focus, and the need for each portfolio to contribute to preventing suicide through targeted action to reduce specific vulnerabilities, while ensuring that the actions and services are linked to the broader suicide prevention system. The Shifting the focus document and decision-making tool was prepared to support cross-portfolio agencies to identify their roles and actions in suicide prevention.
The work of the Adviser and the taskforce was informed by an Expert Advisory Group and a Commonwealth Suicide Prevention Interdepartmental Committee. The taskforce has also engaged high-level officials from the Australian Government, and state and territory governments, and people with lived experience to discuss key priorities for suicide prevention across jurisdictions, and to identify cross-portfolio and cross-jurisdictional priorities. In addition, the taskforce assisted the Adviser to consult further with all jurisdictions and relevant stakeholders to further refine advice as the basis for more intensive and deliberate consultations, before the final advice was provided to the Australian Government in December 2020.