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The rationale for this Report is simple. It is released on the anniversaries of two landmark reports on mental health care in Australia - the 30th anniversary of the Richmond Report and 20th anniversary of the Burdekin Report. The move to deinstitutionalisation is arguably one of the most important public policy ʻdecisionsʼ of the post-war era in Australia. It has had profound impacts on our society and most particularly those affected by mental illness and their families and the mental health workforce. The Richmond and Burdekin reports did not signal the end of mental health reform. They were more likely to start the reform. The aim of this report is to examine what has followed. There have been dozens of inquiries, reports, plans, policies and strategies since 1993, some national, some by the states and territories. Despite all these plans and even the more recent high level engagement of the Council of Australian Governments (COAG) since 2006, this Report asks “How different things really are from when they were originally reported by Richmond and Burdekin, a generation ago?” While some positive changes are clear, there are still far too many reports of service issues and failures when it comes to mental health – “Too many people falling through the cracks”. Despite unequivocal commitments by all State governments in 1992 and reaffirmed in 1998, there are still hundreds of people nationally in every state jurisdiction except Victoria, languishing in institutional settings. We estimate this to be costing taxpayers more than $10 million a week. The life expectancy of people with mental illness has not improved. People with schizophrenia have the same life expectancy as remote Indigenous Australians, but there is no ʻClosing the Gapʼ strategy for schizophrenia. As we now reflect on what has changed since Richmond and Burdekin, Australiaʼs failure to lift the life expectancy of people with a mental illness is arguably the starkest indictment of our public policy failure in relation to mental health care.
Content may be subject to copyright.
Obsessive Hope Disorder
Reflections on 30 Years of
Mental Health Reform in Australia
and Visions for the Future
Summary Report
The image is a computer
generated art image. It shows
an individual attempting to push
a sphere over undulating terrain.
The terrain is certainly uneven
and turbulent and possibly liquid
in form.
This image has been selected
for the Obsessive Hope
Disorder Report to represent
the assembled evidence that
mental health reform has
been undertaken without
solid foundations. Its base is
continually shifting, unstable
and outside the control of those
moving the sphere. The turmoil
of our current federal system of
government, the failure to agree
on national service frameworks
and models of care all contribute
to the constant turmoil within
the mental health system. The
sphere represents the reform
agenda. The solitary gure
pushing or trying to inuence
the sphere is unable to control
it or necessarily push in a given
direction. The solitary individual
on one level is representative
of the bureaucracy acting
in isolation. Clearly more
individuals, and a diversity of
individuals, would help but
they would still expend more
energy than if the terrain was
more stable and uniform. The
lack of light in the image is
representative of the lack of
accountability and clear line of
sight to roles and responsibilities
in mental health. The uncertain
policy basis, inadequate
resources, poor accountability
and measurement mean that
progress toward a clear goal is
never assured - we simply move
the sphere somewhere else not
necessarily “forward”.
Despite all these hardships,
people keep hoping and pushing
the sphere because they want
better mental health services,
and if we acted collectively, then
we’d nd a better way.
Royalty-free image purchased from
SuperStock http://www.superstock.com/
search/Sisyphus
About the Cover Design
This Report has been prepared in
conjunction with:
Obsessive Hope Disorder
Reflections on 30 Years of
Mental Health Reform in Australia
and Visions for the Future
Summary Report
Obsessive Hope Disorder
Reflections on 30 Years of
Mental Health Reform in Australia
and Visions for the Future
Summary Report
John A Mendoza, Amanda Bresnan, Sebastian Rosenberg,
Amy Elson, Yvonne Gilbert, Peter Long, Keith Wilson
and Janet Hopkins
Paper Based Version
© ConNetica 2013
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ISBN print version: 978-0-9922842-3-7
ISBN e-book version: 978-0-9922842-4-4
Dewey Print Number: 362.20994
Dewey E-book Number: 362.20994
Suggested citation for this report:
Mendoza J Bresnan A Rosenberg S Elson A Gilbert Y Long P Wilson K & Hopkins J. 2013. Obsessive
Hope Disorder: Reflections on 30 years of mental health reform in Australia and visions for the future.
Summary Report. ConNetica, Caloundra, QLD.
DISCLAIMER
The Views expressed in this Report are those of the authors unless otherwise indicated. Specific
elements of the research were undertaken by research partners: namely the Centre for Mental Health
Research at the Australian National University, the Brain and Mind Research Institute, The University of
Sydney and the Black Dog Institute at University of New South Wales. Additional work was
commissioned from Carers ACT (Dr Doris Kordes), In2It Consulting (Dr Peter Long) and Practical
Visionaries (Rajiv Ramanathan).
The project partner organisations played no role in determining research methodologies or in analysing,
drafting or editing the findings and conclusions in this Report.
ConNetica and its partners accept no responsibility for the accuracy or completeness of any material
contained in this Report.
Additionally, ConNetica and its partners disclaim all liability to any person in respect of anything, and the
consequences of anything, done or omitted to be done by any such person in reliance, whether wholly or
partially, upon any information contained in this Report.
Obsessive Hope Disorder
2013 i
Acknowledgements
This Summary Report accompanies the Obsessive Hope Disorder Perspectives Report and Technical
Reports.
The (main) Technical Report has been prepared and edited by John Mendoza, Amanda Bresnan,
Sebastian Rosenberg, Amy Elson, Yve Gilbert, Peter Long, Keith Wilson and Janet Hopkins. The report
also includes several chapters and analyses from:
Dr Doris Kordes – on the era of the Richmond Report
Professor Brian Burdekin AO – on his reflections on his 1990–1993 inquiry
Professor Kathleen Griffiths and Bradley Carron-Arthur – for the lead work on the analysis of statutory
authority reports
Tracey Davenport and Professor Ian Hickie AM – the community surveys and analysis
Rajiv Ramanathan – an analysis of the issues for people from culturally and linguistically diverse
backgrounds
Professor Helen Christensen, Katherine Petrie and Phillip Batterham – on the research agenda.
We thank each of our research partners in this work. Their expertise, counsel and contribution are clearly
evident.
We also acknowledge the additional editorial work provided by Mary Hackett and Roslyn Copas and
design and publishing from Bevin Neil at BJN Graphic Design.
We wish to thank the authors of the seventy-nine Perspective Essays contained in this Report who gave
their time to write of their experience of the reform journey, of current services and the challenges ahead.
We are particularly grateful to the consumers and carers, some who wished to remain anonymous, for
sharing their perspective. We commend them for their courage, hope and strength. Their insight provides
the basis for real, enduring reform.
We also wish to thank all of our Project Partners for their faith in the ʻvisionʼ and support in preparing this
Report. In particular:
OMC Connect, our project partner for communications and publication, and its great team of Russell
Bullen, Kelly Pendlebury and Janna Munn.
Our principal funding partner Queensland Youth Industry Links (QYIL).
Our research partners – Centre for Mental Health Research at ANU, Brain & Mind Research Institute
at The University of Sydney, the Black Dog Institute at UNSW, Carers ACT and Practical Visionaries.
The 80+ authors of the Perspective Essays, who have provided a rich and diversity repository of
views on the journey of reform, the present state of mental health in Australia and the way forward for
reform.
The 48 partners who responded to this crowdfunded initiative with both funds and in-kind support.
Finally I wish to thank David Richmond, Brian Burdekin and John Feneley for providing Forewords for the
Report. David and Brian had no reason to commit their time again to this issue. They have made colossal
contributions to mental health reform in the past. We are also grateful to John for putting himself forward
as a current statutory office holder with a large responsibility for mental health reform in NSW.
Conventions used in this summary report
1. Abbreviations are used after the first time a phase is used in full.
2. Definitions relevant to mental health and mental illness are consistent with those used under the
Australian National Mental Health Policy (see http://www.health.gov.au/internet/main/publishing.nsf/Content/
532CBE92A8323E03CA25756E001203BF/$File/pol3txt.pdf).
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Table of Contents
Acknowledgements..................................................................................................................... i
Abbreviations............................................................................................................................. iii
Foreword from David Richmond AO ........................................................................................ 1
Foreword from Brian Burdekin AO ........................................................................................... 3
Foreword from John Feneley .................................................................................................... 5
Preface ........................................................................................................................................ 7
1. Introduction............................................................................................................................. 9
2. A vision for the future .......................................................................................................... 11
3. Our approach: The origins of Obsessive Hope Disorder ................................................. 13
4. The analyses and findings .................................................................................................. 17
4.1 A systematic analysis of national mental health strategy and plans ........................ 17
4.2 The systematic analysis of the statutory authority reports........................................ 20
4.3 The community surveys ................................................................................................. 23
4.4 The thematic analysis of the Perspectives Essays ..................................................... 25
4.5 The commissioned and specific topic analyses.......................................................... 29
5. A better way forward ............................................................................................................ 43
5.1 Some relevant public policy developments ................................................................. 44
5.2 Scaling innovation and evidence-based practice........................................................ 48
5.3 The Manifesto for Change .............................................................................................. 48
6. Obsessive Hope Disorder and a Manifesto for Change ................................................... 49
Appendix A – Key issues and recommendations from
evaluations of national MH plans............................................................................................ 55
Appendix B – List of contributors........................................................................................... 61
Appendix C – Project partners ................................................................................................ 67
Obsessive Hope Disorder
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Abbreviations
ABS Australian Bureau of Statistics
ACU Acute Care Unit
AHMAC Australian Health Ministers Advisory Committee
AHMC Australian Health Ministers Council
AICAFMHA Australian Infant, Child, Adolescent and Family Mental Health Association
AIFS Australian Institute of Family Studies
AIHW Australian Institute of Health and Welfare
ANU Australian National University
ATSI Aboriginal and Torres Strait Islander (Indigenous)
BEACH Bettering the Evaluation and Care of Health
BOiMHC Better Outcomes in Mental Health Care Program
CMMHS Community Managed Mental Health Services (NGOs)
CoAG Council of Australian Governments
CoAG NAPMH Council of Australian Governmentsʼ National Action Plan on Mental Health
2006–11
CTO Compulsory Treatment Order
DEEWR (Commonwealth) Department of Education, Employment and Workplace
Relations
DoHA (Commonwealth) Department of Health and Ageing
DVA Department of Veterans Affairs
ED Emergency Department
EPPIC Early Psychosis Prevention and Intervention Centre
FaHCSIA Department of Families and Housing, Community Services and Indigenous
Affairs
GPs General Practitioners
HEROC Human Rights and Equal Opportunity Commission
MHCA Mental Health Council of Australia
MHS Mental Health Services (Public)
NACMH National Advisory Council on Mental Health
NHA National Healthcare Agreement
NHRA National Health Reform Agreement
NHHRC National Health and Hospitals Reform Commission
NMDS National Minimum Data Set
NMHC National Mental Health Commission
NMHS National Mental Health Strategy
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iv
NMHP or Plan National Mental Health Plan (with number)
NSPS National Suicide Prevention Strategy
PBS Pharmaceutical Benefits Scheme
PDRS Psychiatric Disability Rehabilitation Service
PHaMs Personal Helpers and Mentors Program
PM&C Department of Prime Minister and Cabinet
ROGS Report on Government Services (issued by Productivity Commission)
WHO World Health Organization
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Foreword from David Richmond AO
The “Cinderella” of health services was the 1983 description of the then mental health scene as seen
through the eyes of the Richmond Report into services in New South Wales. The Report, Obsessive
Hope Disorder: Reflections on 30 years of mental health reform in Australia and visions for the future,
clearly demonstrates the continued relevance in 2013 of this comment.
Mental health is still underfunded and continues to be locked into hospital care, albeit often smaller in
scale, more localised and more closely aligned with other health services than in the past. This mode of
service configuration appears largely provider driven when compared, for example, with client and family
priorities.
Obsessive Hope Disorder highlights the challenge of implementing reform and the inability, despite
numerous “pockets” of excellent practice, to achieve a coherent, integrated, sustainable and client-friendly
system. The authors advocate the need for fundamental realignment of governance and funding models
at national, state and local level in order to achieve consistency in accessibility to services across
Australia.
The authors and contributors are to be congratulated on their diligent documentation and analysis of the
events, issues and data over these years. Most importantly, this comprehensive Report also captures
personal and professional perspectives from those who have participated in this journey.
An important theme is the need for comprehensive high quality, coordinated and flexible care. This
requires greater legibility and visibility of services. In particular, clear entry points and subsequent
pathways or “streams of care” within Health and in areas of community services which impact on
individual wellbeing and welfare.
The 30 year period reviewed has been one of very significant social, economic and technological change,
particularly in medical science and information and communications. Some of this has assisted reform
but much has simply made the health services environment more complex and more competitive. On the
demand side significant changes have also made services more complex, for example, the growth in
consumption of both legal and illegal drugs.
The context and analysis within Obsessive Hope Disorder needs to be placed alongside much of this
change, particularly significant changes in urban housing and accommodation markets and in the nature
and structure of employment markets. Social attitudes to mental health issues also continued to evolve.
It is no coincidence that issues such as housing and accommodation, employment, social inclusion and
avoidance of stigma are still highlighted as key challenges.
An important change has been the strengthening of human rights. A complementary trend has been the
growth of the consumer movement including consumer participation in services. Devolution of services to
local levels and to the non-government sector and attempts at linking services to outcomes through
activity-based funding, brokerage or purchase models are also relevant themes. These changes can
contribute to greater transparency and accountability.
Models of support and care continue to evolve. Enabling people to get as well as they can, and stay well
with tailored levels of support and assistance is paramount. Obsessive Hope Disorder provides many
useful insights into how an improved system might be fashioned and recommends many of the steps
needed to achieve an effective national approach.
Summary Report
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The Reportʼs analysis, based on evidence-based research, around the efficacy of specific service delivery
elements and their role and place in the continuum of care and support is particularly instructive; as is the
discussion about the nature of systems and the need for a paradigm shift in service delivery thinking.
Importantly, “systems” thinking is expressed in a broad context recognising both the vital ongoing role that
medical science and treatment play and the significance of wider social and economic elements in
contributing to individual wellbeing.
This meshing of scientific advances, improvements in social infrastructure, greater focus on evidence-
based service outcomes, governance reform, and consumer participation is a way forward. The ability,
however, to analyse and synthesise the economic, political, social, scientific and systems knowledge and
experience we possess and then to mobilise reform through advocacy appears currently beyond our
fragmented system of mental health services.
This is a void waiting and needing to be filled – perhaps by entities such as recently established Mental
Health Commissions and Commissioners. Obsessive Hope Disorder throws up challenges which
urgently require vigorous advocacy and broadly based community and political leadership.
David Richmond AO
Sydney, July 2013
Chair of the Richmond Inquiry into Health Services for the
Psychiatrically Ill and Developmentally Disabled, 1983
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Foreword from Brian Burdekin AO
The extensive and widely sourced research assembled in this report, Obsessive Hope Disorder:
Reflections on 30 years of mental health reform in Australia and visions for the future, is a very important
and timely contribution to informing efforts to more adequately protect the rights of Australians affected by
mental illness.
Good research is always important to formulating realistic recommendations for effective policies and
programs and dispelling ignorance and prejudice. It is also absolutely essential in facilitating effective
advocacy by or on behalf of a group or groups who have been routinely ignored, politically disempowered,
ostracised, marginalised and even victimised for centuries – as those affected by mental illness have
been in virtually every society – including Australia.
Our report on "Human Rights and Mental Illness" 20 years ago, based on evidence from those directly
affected and their families and carers, documented appalling violations of human rights affecting
hundreds of thousands of our fellow Australians – and sometimes their families and carers as well. The
evidence we heard in every State and Territory was an unanswerable indictment of inhumanity and official
omission and neglect.
There were many reasons for this. They included the deficiencies of our legal system (the much vaunted
common law system – fine in theory, but an abysmal failure in reality) inadequate training for our doctors
widespread ignorance in our community associated with irrational fear; discrimination; stereotypes and
myths; chronic underfunding; and the indifference of our major political parties compounded by the
vagaries of our Federal system and the inadequacies of "democratic systems" in protecting the rights of
vulnerable minorities.
But Australia is one of the wealthiest counties in the world – so while there were reasons, there were no
justifications.
Shamefully, our Federal Government had solemnly ratified international treaties prescribing equality and
proscribing discrimination – but abdicated virtually all responsibility for assisting those affected by mental
illness. In summary, the evidence from carers, consumers, clinicians, concerned health workers and
community organisations clearly established that the abuse, discrimination and neglect suffered by
mentally ill Australians were both systemic and systematic.
The national inquiry we conducted had results – including many legal, policy and programmatic reforms,
an injection of substantial resources – and for the first time, in response to the evidence, the Australian
Government produced a National Mental Health Plan. But, as this current report attests, the follow up was
inadequate and under-resourced. We still have a long way to go.
Recommendations in this report are directed to narrowing the gap between the rhetoric of commitment
and the reality of delivery. I sincerely hope they will receive the support they deserve but that will require
sustained advocacy – from all of us!
Prof. Brian Burdekin AO
Sydney, July 2013
Federal Human Rights Commissioner, and Inquiry Head,
Human Rights and Mental Illness Inquiry, 1990–1993
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Foreword from John Feneley
Some of the most powerful chapters in this extraordinary report are the individual testimonies from people
who live with mental illness, in their own lives or as carers. They show how people may miss out on
finding the support they need if services that do not join up properly, or are made available in arbitrary or
inconsistent ways. And they reveal the consequences for individuals of such service failures: sometimes
tragedy; more often lives lived on the margins, with reduced opportunity to pursue personal, relationship
or career goals.
Three decades ago, Australia began in earnest to reform mental health care, recognising that isolating
unwell people in secure facilities could not be justified in a humane society. But reform to date has
focused on systems. We jettisoned one mental health system built around institutions, and patched
together another out of hospital wards, hardworking community teams and non-government service
providers, medication and wishful thinking.
For those responsible for them, systems can be a comfort. We can debate interminably whether it is the
responsibility of the Commonwealth or the states to fix particular system problems. We can measure who
goes into the system, what drugs they take, how long they stay and how many times they return. We can
see how much a system costs, and adjust it by applying or withholding money. But monitoring the system
tells us almost nothing about whether it is meeting the real needs of the people it should serve. Does an
episode of mental health care help someone find or keep a job? Does it improve how they relate to their
child, or make it easier for them to make an important phone call or greet a neighbour? Does it support
people to look after their own physical health?
To take reform to the next level we must remain mindful of organisational issues, but we must also
develop much deeper knowledge about how systems work for people, keeping at heart the values of
respect for individuals and their right to choose how they wish to live – including the right to choose what
care and support they use.
We must also extend our watch beyond government, and take responsibility for educating and supporting
everyone – employers, insurers, librarians and sports coaches – to promote good mental health and
respond constructively and kindly to people who experience mental illness.
The creation in Australia of mental health commissions nationally and in three states is an
acknowledgement that there is something special about mental health; that it does not sit neatly within a
broader health system focused on acute illness. Effective mental health care is not about administering
treatment and hoping for a response; it needs to recognise the entire context of peopleʼs lives.
The NSW Mental Health Commission has been given explicit responsibility to recommend improvements
to the support offered to people who experience mental illness, not just within the health portfolio but
encompassing housing, justice, family and community services, education. People tell us these things
may be as important as health care, or even more so, in their ability to live a fulfilling life in which mental
illness is not the dominant theme but just another circumstance.
We must also look beyond the boundaries of state government and recognise that the supports people
seek may be provided by the Commonwealth, community-managed organisations or the private sector.
Our challenge now is to create and maintain momentum for a new generation of changes.
John Feneley
Sydney, July 2013
Mental Health Commissioner of NSW
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Preface
The year 2013 marks the 30th anniversary of the Richmond Report and Inquiry into Health Services for the
Psychiatrically Ill and Developmentally Disabled. In Australia, 1983 was a big year in many ways – the
Ash Wednesday fires ripped through Victoria and South Australia killing 71 people, the Hawke
Government was elected in March, Australia II won the ʻAuld Mugʼ from the Yanks, the nationʼs first case
of AIDS was reported and if one could afford a new car, it was often a Holden Kingswood. Perhaps more
profound than many realised at the time was the decision in December 1983 to float the Australian dollar
by Treasurer, Paul Keating.
Coincidentally, 2013 also marks the 20th anniversary of the Human Rights and Equal Opportunity
Commission (HREOC) Inquiry into The Human Rights of People with a Mental Illness. In 1993 Paul
Keating won the unwinnable Federal election, Sydney was announced as host city for the 2000 Olympic
Games, two great Australians, Edward ʻWearyʼ Dunlop and Fred Hollows, passed away, unemployment
was nearly at 11% over the full year and again, more fundamental for the nation in many respects, the
Native Title Act came into law following the High Courtʼs Mabo decision.
When the Human Rights Commissioner, Brian Burdekin, commenced his Inquiry in 1990, there was no
national approach or strategy in relation to mental health. By the time Burdekin had finished, all
Australian Governments had signed off on a National Mental Health Statement of Rights and
Responsibilities (1991), a National Mental Health Policy (1992) and a 5-year National Mental Health Plan
(January 1993).
The rationale for this Report is simple. The move to deinstitutionalisation is arguably one of the most
important public policy ʻdecisionsʼ1 of the post-war era in Australia. It has had profound impacts on our
society and most particularly those affected by mental illness and their families and the mental health
workforce. The Richmond and Burdekin reports did not signal the end of mental health reform. They
were more likely to start the reform. The aim of this report is to examine what has followed. There have
been dozens of inquiries, reports, plans, policies and strategies since 1993, some national, some by the
states and territories. Despite all these plans and even the more recent high level engagement of the
Council of Australian Governments (COAG) since 2006, this Report asks “How different things really are
from when they were originally reported by Richmond and Burdekin, a generation ago?”
While some positive changes are clear, there are still far too many reports of service issues and failures
when it comes to mental health – “Too many people falling through the cracks”. Despite unequivocal
commitments by all State governments in 1992 and reaffirmed in 1998, there are still hundreds of people
nationally in every state jurisdiction except Victoria, languishing in institutional settings. We estimate this
to be costing taxpayers more than $10 million a week. The life expectancy of people with mental illness
has not improved. People with schizophrenia have the same life expectancy as remote Indigenous
Australians, but there is no ʻClosing the Gapʼ strategy for schizophrenia.
As we now reflect on what has changed since Richmond and Burdekin, Australiaʼs failure to lift the life
expectancy of people with a mental illness is arguably the starkest indictment of our public policy failure in
relation to mental health care.
1 There was no clear decision or date when the change began as such. The earliest evidence of deinstitutionalisation dates from the mid-1950s in
Australia.
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1. Introduction
Mental health services have had a long and controversial history in Australia. While most of the states
established asylums in the mid-1800s, significant public debate and concern was apparent by as early as
1870, evidenced by the establishment of two Royal Commissions in 1870 and again in the early part of
the 20th Century2. These commissions were ordered to qualify the existing management structures, which
had been suggested to be ʻunaccountable and arbitraryʼ3.
Over the past thirty years since David Richmondʼs landmark report in 1983, there has been a continuation
of many more controversies relating to mental health and mental health care in Australia. Just this year, a
prominent controversy has been the release of the Diagnostic and Statistical Manual of Mental Disorders
– V (DSM 5) – its very validity openly questioned from within and beyond the mental health profession.
We continue to see reports, almost daily, of system failures – from the demand on police service
resources, to personal tragedies involving suicide or police shootings of people with mental illness, to
reports from statutory authorities of systemic problems. “People falling through the cracks” is almost a
new euphemism for reporting “situation normal” with our mental health care ʻsystemʼ.
A common and prominent theme over the past three decades is the lack of accountability and outcomes
data. Astonishingly, attributes identified as systemic problems over 100 years ago are still evident today.
More concerning than this representing a failure of basic governance, is that, in examining the origins of
mental health reform, one can uncover the same findings and recommendations in Dr Allan Stollerʼs
report from 1954, David Richmondʼs 1983 report, Professor Brian Burdekinʼs report in 1993 and the NSW
Ombudsmanʼs report in December 2012.
This Report, Obsessive Hope Disorder, sets out to document aspects of the journey of reform since David
Richmondʼs report. It provides an assessment of where we are now on that reform journey. Finally, it
sets out a better way to go about reform from this point.
It is also evident that there are examples of real reform and progress in developing effective and efficient
models of mental health care. The example set by the Australian Capital Territory, as a somewhat
discreet system, clearly shows that with strong and sustained political leadership, new investment,
effective public administration and genuine engagement with the community, transformation of services
can advance well within two terms of government.
Clearly, Australia cannot wait another generation before attitudes and beliefs about mental health are on
par with those evident for our common physical health conditions and disabilities. Clearly we cannot
continue with the institutional discrimination evident in the allocation of resources for mental health care.
Why should we accept that a person with a mental illness has lesser rights than a person with cancer, or
cardiovascular disease or respiratory disorders? Why is it accepted that they must wait patiently for
access to effective care? Clearly, we cannot afford to sit back and repeat the wanton waste evident in
many of the reform initiatives over the past three decades and hope that they work. As a nation we
cannot afford the cost – in personal, social and economic terms – to continue with ʻbusiness as usualʼ.
2 Garton S 1988. Medicine and Madness: A Social History of Insanity in New South Wales. NSW University Press, Sydney NSW.
3 Henderson J 1993, cited in Wadham B 2004. The National Mental Health Policy and Social Change. Unpublished Thesis, Flinders University.
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2. A vision for the future
The history of Australian mental health reform over the past three decades is one of world class policies
and strategies let down by inadequate planning, poor implementation and our complex system of
government. The results have been disappointing, wasteful of scarce resources and all too often,
devastating for the millions of Australians affected by mental illness.
Despite this, many consumers, carers and people working in mental health remain positive. They are
afflicted with a condition known as obsessive hope disorder, a condition which permits them to
understand mistakes of the past and plan a better future for mental health. Obsessive hope disorder
(OHD) is characterised by a willingness to keep hoping, keep dreaming.
We strongly believe that OHD can be cured, that mental health reform is both practically possible and
enjoys overwhelming community support. From the evidence and the analysis presented in this Report,
the key to curing OHD is immediate attention to five urgent elements of reform: governance; quality of
care; our workforce; research and evaluation; and funding.
We will know we have been successfully if in five, ten and 20 years we will see tangible, measurable and
defined outcomes including but not limited to:
In five years hope is replaced by reality. There will be:
Robust planning, policy and accountability.
National frameworks and service models.
Increased funding relative to overall health spending.
Alignment between the different levels of Governments and a clear line of sight to services and to
service users and communities.
Nationally harmonised laws that will protect the rights of all people affected by mental illness and their
families.
A workforce that feels valued and respected and is supported with continuous investment in training
and development.
Services that are co-designed and managed by communities.
The infrastructure to support Australia as world leaders in mental health research and development.
In 10 years:
Access to care for high prevalence mental health disorders will approach that of high prevalence
physical health conditions (70% overall, 60% for men).
The quality of care will be in accordance with guidelines for 70% of episodes of care for the sixteen
most common mental health disorders.
In a generation:
The life expectancy of people with severe mental illness is greatly improved, narrowing significantly
the gap between this and the average life expectancy for the total Australian population.
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3. Our approach: The origins of Obsessive Hope Disorder
This is the story of the origins of this project and the Report you are now reading. It is the culmination of a
long journey, one that is far from over.
Still having the same conversation
In late 2011 over a coffee with a colleague in Brisbane, it became apparent we were still having the same
conversation – namely that we still did not have a cohesive, easily accessible mental health system in
Australia. That same conversation was repeated around the country with colleagues: in spite of
numerous reports and reviews, mounting evidence about what works and what does not, recent
increased attention and investment from multiple governments – we still did not have a ʻsystemʼ as such.
It was approaching thirty years since David Richmondʼs landmark report and twenty years since the
Burdekin Inquiry. Over that coffee in 2011, the discussion turned to what had changed? The short
answer was ʻnot enoughʼ. It was clear we were still talking about problems across all spheres of mental
health and it was clear that good intentions had not lead to effective, sustained improvements. Why else
would 130,000 Australians have signed the GetUp! petition for mental health reform in 2010?4 It was
clear that this mattered to many, many ordinary Australians.
The GetUp! petition made its mark and the Federal Budget of 2011 included a $2.2 billion package of
reforms. But despite this and claims that “the last few years been quite transformational (for) federal
mental health policy in particular”5, the challenges in mental health have never been clearer and appear
to remain far off.
This realisation sparked the beginnings of this Report. It was time to stand back, to take stock, to reflect
and to review. We committed in late 2011 to tell the story – the journey of reform and why we were still
having too many of these conversations. Yet we knew there were already more than enough books,
reports and professional articles chronicling the parlous state of mental health services. This had to be
different.
The vision for the Report
It had to be independent. It had to be real. It needed to bring along and speak to the people that matter.
Those 130,000 Australians and the many more who appeared to recognise things were not right with
mental health care6. Maybe it was and still is ʻcrowd wisdomʼ, but clearly as with Indigenous
disadvantage, Australians wanted their governments to do a much better job on mental health.
What we also knew, in scoping this project and report, that for too long the voices of dissent had been
squashed, ignored and marginalised. The ʻairbrushing of dissentʼ has been a common experience.
The thirty-year anniversary of the Richmond Report in 2013 provided the extra impetus of a deadline. The
journey began.
A collective approach
The current state of the mental health system in Australia was not the result of any one individual,
government or organisation. Nor could any one individual, government or organisation remedy ʻitʼ.
Rectification will take a collective approach to bring true, lasting reform. Rectification will require a
ʻmovementʼ. Rectification will not be through incremental improvements or ʻbusiness as usual with a cash
splashʼ.
4 This response was the strongest GetUp! had received on a single issue up until then.
5 The Hon Mark Butler, Federal Minister for Mental Health, Speech at ORYGEN Youth Health, 13 June 2013.
6 In the same speech Mark Butler states “that for some years now there had been a bubbling sense of unease in the community that mental health
services were not hitting the mark in Australia. That, following the deinstitutionalisation of the sectors, and then in the early '90s the finalisation of that
process and mainstreaming of acute mental health services into the general hospital system, there had been a distinct lack of follow-up by all state
governments across the country, Labor and Liberal alike, in investing in the community services that were supposed to be the flip side of
deinstitutionalisation.”
Summary Report
14
For this project to move from conversations to reality, funding was needed. Resources were scarce but
interest was strong. The conversations began and the project gathered momentum. By August 2012
there were a core group of 15 partners signed on.
The scope evolves
In late August 2012 the first meeting of partners was held in Sydney and scoping started in earnest.
There was much to say, a lot of ideas and excitement and an ambitious agenda was developed. The
scope grew. Collectively we would do more than create a report; we would seek to enhance the value
and impact of the project by taking advantage of the latest digital platforms to engage and involve as
many people across Australia as possible. There was a desire to capture the true picture of the mental
health reform journey for ordinary Australians across all walks of life. Importantly, there was a strong
desire to reflect on successes and gather information on what is working and why.
The project scope now included:
Two national surveys
Topic reviews, data analysis, research, and historical document reviews
Purposive sampling and analysis.
These were developed into the:
Technical Report, detailing the results, conclusions and recommendations
Perspectives Report, with over 80 individual and group submissions
Summary Report.
These would be supported and launched through a public campaign to inspire a movement:
The ʻswYtch the conversationʼ website as the hub, offering a place to:
Share experiences
Share visions
Share solutions.
Integrated social media, Facebook, Twitter, Instagram and YouTube
Television commercial (TVC).
Crowdfunded
The partnership group has been actively involved in shaping this project from the very beginning. In fact,
this report has effectively been ʻcrowdfundedʼ in both capital and material.
As the ambitions of the group took shape, the scale of the project grew. More resources were required.
Interest strengthened and word of mouth attracted more partners. The original partnership group
gradually expanded and as the Report goes to print now includes 48 diverse partner organisations. It will
continue to grow following the release of this Report. It is not an exclusive club; it welcomes new
members with passion, drive and a shared vision for a better way.
Obsessive Hope Disorder
With support and vision the project has reached an important milestone with the release of this Report,
Obsessive Hope Disorder: Reflections on 30 years of mental health reform and visions for the future.
Together with the Perspectives Report, it provides a detailed picture of the Australian mental health
reform journey so far.
Obsessive Hope Disorder
ConNetica 15
This Report is just the start of a new conversation. Its release is an opportunity to bring wider attention to
the issues it raises. Mental health reform is not ʻdoneʼ yet. Whilst mental health has attracted more
funding in recent years, it is still a long way short of what is needed. Importantly we need to recognise
that responsibility for future reform extends beyond the Government to all of us. We now see frequently in
recent government policy and program documents that mental health is everyoneʼs business. Indeed it is
everyoneʼs business: governments will never be able to solve the issues alone. It will require collective
action to achieve collective impact…and a truly effective and accessible mental health system for all of
us.
Figure 1 shows the story of the project in an infographic.
Overview of the research methodology
This Report has been informed by a mixed method approach to the research. Triangulation of data,
methods, sources and researchers has been used to provide a more comprehensive and deeper
understanding of the state of mental health and mental health services in Australia. Five key analyses
have been undertaken to inform the findings and recommendations in this Report:
A systematic review of the National Mental Health Strategy and the commitments made under each
Plan, the results reported by government agencies and the results of the evaluation.
A systemic review of 32 independent, statutory authority reports specifically dealing with mental
health service issues. These cover the years from July 2006 until December 2012.
Community surveying on recent consumer and carer experiences of service, community assessments
of the implementation of reforms and a comparison with replica surveys from 2004.
An analysis of a purposive sample of seventy-nine individual perspectives on reform, the current state
of mental health and the future needs.
Commissioned analyses and reviews – a review of the Richmond era changes; a review of the mental
health needs of people from culturally and linguistically diverse backgrounds; a review of the research
agenda; and a review of the mental health workforce – its past, present and future.
The research team also undertook a review of the prevalence and impacts of mental illness in Australia
and the policy and program initiatives of all Australian nine governments focusing on the period since July
2006. All state and territory governments were sent summaries for comment.
Details regarding the methodology of each research component can be found within the methodology and
findings section of this report.
Figure 1: The project journey (next page)
Summary Report
16
Obsessive Hope Disorder
ConNetica 17
4. The analyses and findings
4.1 A systematic analysis of national mental health strategy and plans
Since 1992, Australia has had a National Mental Health Strategy (NMHS) agreed to by all governments
and tied to the national healthcare agreements. This has consisted of:
two National Mental Health Policies
four National Mental Health Plans (NMHP or the Plan/s)
the Mental Health Statement of Rights and Responsibilities (issued twice)
one five-year Council of Australian Government (COAG) National Action Plan
the National Mental Health Commissionʼs Report Card “A Contributing Life”
the CoAG Road Map for National Mental Health Reform 2012–22.
In addition, there are also dozens of various state and territory plans and strategies relating to mental
health; for example, New South Wales has six specific plans relating to mental health, plus the NSW
State Plan and the NSW State Health Plan7. Added to this, are the National Health Reform Agreement
(NHRA) 2011 and the National Healthcare Agreement (NHA) 2012, both of which include a mental health
stream.
The NMHS was first endorsed by the Australian Health Ministersʼ Conference (AHMC) in 1992 as a
framework to guide mental health reform in Australia8. The four plans cover the following periods:
First National Mental Health Plan 1992–1997
Second National Mental Health Plan 1998–2003
Third National Mental Health Plan 2003–2008
Fourth National Mental Health Plan 2009–2014.
The development of the NMHS in 1992 was the first attempt to coordinate mental health services
nationally, in an area which had been the responsibility of states and territories9. Reviews have been
undertaken of each of the national plans, except the fourth which is still current.
The current policy environment for mental health has led to the situation where, despite the proliferation of
plans, report cards, and strategies at a national and state/territory levels, there has been little progress in
determining the outcome of the investments made in mental health services and reform. Simply put, we
cannot tell if people with a mental illness are better off than they were ten or twenty years ago.
The method
The analysis for this Report draws upon the plans, the subordinate implementation plans, the
commissioned reviews or evaluations and other government data sources such as the Report on
Government Services (ROGS) prepared by the Productivity Commission.
In order to analyse the impact of the NMHPs over the past twenty years, six key areas in mental health
have been examined to look at what progress has been made, and whether the federal and the state and
territory governments have implemented the commitments they have collectively and individually made
under the national plans. The areas analysed are:
Housing and accommodation
Employment
7 NSW Government, Health, Mental Health, Drug and Alcohol Key plans and strategies, viewed 15 May 2013,
http://www.health.nsw.gov.au/mhdao/plan_strategy.asp.
8 Australian Government, Department of Health and Ageing, Mental Health, viewed 15 May 2013,
http://www.health.gov.au/internet/main/publishing.nsf/content/mental-strat.
9 Whiteford H Buckingham B Manderscheid R 2002. Australia’s National Mental Health Strategy, British Journal of Psychiatry (2002) 180, Royal
College of Psychiatrists, UK.
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18
Social inclusion
Stigma
Provision of and access to services
Measureable targets and accountability.
The findings
The result is disturbing if not alarming. Repeatedly the same issues are identified as priorities for action
and repeatedly the reviews and available data point to policy implementation failure, or partial or
inconsistent implementation. Appendix A presents a table summarising the key themes.
Measurement and accountability – a case example
In this Report Summary, we have taken just one of the six themes to illustrate the problem evident in the
development, deployment and evaluation of National Mental Health Policy since 1992.
The Fourth National Mental Health Plan released in 2009 states that improving accountability for both
mental health reform and service delivery are central to the Fourth Plan”. It goes on to state the priorities
in relation to accountability, namely:
Establish comprehensive, timely and regular national reporting on the progress of mental health
reform which responds to the full range of stakeholder needs.
Build an accountable service delivery system that monitors its performance on service quality
indicators and makes this information available to consumers and other stakeholders.
Further develop mental health information, including national mental health data collections, that
provide the foundation for system accountability and reporting.
Conduct a rigorous evaluation of the Fourth National Mental Health Plan.
However, the First Plan and policy twenty years ago states in relation to monitoring and accountability:
There needs to be greater accountability and visibility in reporting progress in implementing the
new national approach to mental health services. Currently mental health data collection is
inconsistent and would not be adequate to enable an assessment to be made of the relative stage
of development of the Commonwealth and each State/Territory Government in achieving the
objectives outlined in the National mental health policy. …. It is essential that such a consistent
system of monitoring and accountability be created. In developing such a system, it needs to be
recognised that each State and Territory will be at a different stage as a result of the historical
development of its mental health system. The central approach should be to measure progress in
each State and Territory.
The First Plan goes on to list specific objectives in this area, namely:
To develop nationally agreed measures of performance in relation to each of the objectives in this
policy and others which the Commonwealth, States and Territories regard as indications of
performance in relation to this policy.
To report annually and publicly, in a timely fashion, on the progress of the Commonwealth and each
State and Territory in relation to these performance indicators and to compare them to their previous
performance10.
10 Extract from the National Mental Health Policy, Canberra, 1992.
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In each of the subsequent plans and evaluations since 1992, the issue of meaningful, timely measures is
revisited and “the need to develop, agree and implement” identified. The Third Plan (2003)
acknowledged national monitoring as important and stated that measurable indicators ʻshouldʼ be agreed
on early in the life of the plan. Then in 2008, the Fourth Plan again makes improving accountability “as
central to the plan”.
The First Plan Evaluation in 1998 noted that measurement and monitoring of service quality remained a
challenge and progress in implementing standards for mental health care had not met expectations.
Despite significant developments in the availability of mental health data, it was not possible to monitor
changes over time or the levels of unmet need. With regards to the National Standards for Mental Health
Services, progress in implementing them had been slower than expected and consumers, carers and
service providers thought it was unsatisfactory. It stated that achieving a commitment from all
jurisdictions would extend well beyond the Second Plan, and that the challenge was to embed continuous
quality improvements rather than just the review of services against the standards.
Mental health workforce practice standards are also discussed and it was anticipated these would
promote clinical best practice, and potentially promote a ʻhumanʼ approach to service delivery. However,
the implementation of initiatives had been hampered by the attitudes and practices of the mental health
(MH) workforce and until the sector itself championed them, progress would continue to be unacceptable.
The Third Plan in 2003 acknowledges that a major issue from the Second Plan Evaluation was
accountability regarding resource use and service quality, and that mechanisms are required to ensure
accountability on funds spent on services for service development and achieving outcomes.
In the priority area of the Third Plan “Strengthening quality” standards and monitoring is highlighted, with
the need to move from an emphasis on service input and structure to impacts and outcomes. The
evaluation five years later in 2008 states that frustrations expressed by stakeholders included that the
Third Plan did not give specific guidance towards actionable and measurable items. The Third Plan was
too broad by trying to ʻbe all things to all peopleʼ and the key directions or outcomes could not be
identified as accomplished since the actions required were not clearly defined.
Data and evidence for better mental health outcomes was identified in the Third Plan Evaluation. This
was a “Group One Priority Recommendation”: namely a national performance management framework.
There was a need expressed for establishing and measuring clearly defined targets at the national level
(e.g. reducing and eliminating seclusion and restraint). Yet we know that as of June 2013, there is still no
national available data on restraint and seclusion. Reporting on matters related to basic human rights are
not routinely collected or reported.
The Third Plan Evaluation, completed in 2008, recommended performance arrangements should also
include the national standards for care providers and agreed incentives and sanctions for service
providers who do not agree to or meet the standards. The evaluation goes on to list in some detail the
features of such a performance system. One could be forgiven for thinking the authors were somewhat
frustrated with having to repeat themselves, and therefore decided to spell it out.
The following figure depicts the cyclical nature of the mental health plans and the recommendations
expressed in the commissioned evaluation reports.
Summary Report
20
Figure 2: Mental health policy and the 5-year Groundhog Day experience
The most recent ROGS Report (2013) points to one of the key factors in the difficulties in delivering the
intentions of mental health policy where it repeats many of the same recommendations on the need for
robust measures on efficiency and effectiveness of mental health services11.
Twenty years of the National Mental Health Strategy and the five-year plans and other strategies, such as
the COAG National Action Plan, has delivered information, monitoring and reporting which tells very little
about the state of mental health and mental illness in Australia. Despite the national collaborative
framework, there is a lack of real accountability and a reliance on limited mental health service (MHS)
systems data12.
Current payment arrangements are historical (you get what you got last year plus or minus something) or
based on the number of services provided. These approaches are straightforward in comparison to
measuring outcomes or performance. Less than a third of required key performance measures for public
mental health services were available for recent government reporting. Even the reports prepared for
COAG and First Ministers13 has been dogged by delays and incomplete data. As at 30 June 2013, the
report for the final year (2010–11) of the COAG National Action Plan is still not available.
The failure to collect outcome data points to the need to have such data collected and reported on by a
dedicated research body or appropriately empowered statutory body14.
Assessing the progress of the state and territory jurisdictions against the National Strategy was beyond
the scope of this project. Nonetheless, from the analysis of all jurisdictionsʼ policies and programs, it is
clear that there is, and has been throughout the past 20 years, an almost complete lack of alignment in
timeframes, strategies or priorities between the national and state/territory planning documentation.
Without nationally-agreed incentives or sanctions, jurisdictions have largely done whatever they want,
whenever they want.
4.2 The systematic analysis of the statutory authority reports
The method
The Centre for Mental Health Research at ANU led this aspect of the research for this Report. The
results are presented from a systematic review and synthesis of the findings of National and State audits
of mental health and related services undertaken by independent statutory authorities such as
ombudsman, auditors, public advocates, guardians and commissioners.
11 Report on Government Services 2013, Productivity Commission, Australian Government 2013.
12 Crosbie, D, Mental health policy – stumbling in the dark? MJA, Volume 190 Number 4, 16 February 2009.
13 ‘First Ministers’ is the term given to refer to the Prime Minister, Premiers and Chief Ministers – the heads of Australia’s nine Governments.
14 Op cit, Crosbie.
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A total of thirty-two (32) reports were reviewed from the period July 2006 to December 2012. In some
cases, the reports on which the review is based were initiated by the office undertaking the review; others
were prompted by public complaints, requests by a government, Parliament or Legislative Assembly or
constituted part of the officeʼs statutory functions (e.g. annual review of child deaths). In all cases the
resulting report was undertaken independently of the government and the departments or agencies
responsible for program management and/or program implementation. There were additional reports (19)
identified in the initial stages of this review but were not retained for detailed analysis.
These statutory authority audits and reviews do not analyse all aspects of the mental health care system.
Nor, in the case of State and Territory focused audits, do they investigate the system outside a particular
jurisdiction. Moreover, unless policy makers act quickly to implement the recommendations of these
reports, their findings can quickly lose currency. Nevertheless, the reports represent the culmination of
careful and systematic investigation of important questions by trained, independent investigators and the
outcomes may be informative both as they apply to the jurisdiction and topic evaluated and for their
potential applicability to other jurisdictions and topics.
It was determined to commence this systematic review from the year 2006. This was a relevant ʻstart line
as it was the beginning of what could be termed the ʻCoAG interventionʼ following the release of the Not
for Service Report in October 2005. To our knowledge a systematic review of the independent reports
from statutory offices relating to mental health services has never been previously done.
Figure 3: Distribution of the included reports
National ACT NSW NT QLD SA TAS VIC WA TOTAL
Auditor General 2 1 1 1 1 6
Ombudsman 2 6 1 1 1 11
Public Advocate 1 1
Child Safety Commission 1 5 1 1 4 12
Human Rights Commission 2 2
Public Trustee
TOTAL 4 3 8 0 5 3 0 3 6 32
The findings
The findings from our analysis are presented and relate to the different points of the mental health service
spectrum. Although many of the reports identified positive achievements of the agencies and staff they
reviewed, every report found problems with the current system and recognised areas requiring change.
Areas requiring improvement in one or more jurisdictions included:
Mental health awareness in the community, particularly with respect to awareness that young
people can experience mental illness and need to treat threats to suicide seriously.
Prevention services for young people in schools and the prevention of mental illness in particular
groups.
Community based mental health care where there is a particular need for improved access to
services in the community and for an increased focus on early intervention and rehabilitation and
appropriate planning to ensure the mix of services meet consumer need15. The need to improve
continuity of care and interagency cooperation in the community sector was another strong theme to
emerge from the reviews.
15 In addition to a need for improved access to the general community, particular groups requiring improved access include children with mild to
moderate mental health problems, adults and young people in justice settings (and those with behavioural problems that place them at risk of entering
the justice setting), women during the perinatal period, people living in rural and remote regions, Australians of Indigenous background, young people
from culturally and linguistically diverse backgrounds and young people who are homeless.
Summary Report
22
Crisis response where dignity and respect are paramount. There is a need to improve the
adherence to the protocol that states that consumers should be transferred to hospital by ambulance
and not police van unless this is not possible for safety reasons.
Emergency unit responsiveness: There was little consideration of care in hospital emergency units.
Inpatient care where inadequate access to inpatient care was a significant issue for young people,
those from rural and remote regions and those in forensic settings. There was also inappropriately
lengthy waits in emergency units pending admission to a ward, poor practices with respect to
informing consumers about their rights, ensuring privacy, and with respect to the use of restraint,
seclusion and search.
Housing where there is a need to increase the availability of supported accommodation for
consumers, and to thereby reduce the number of consumers who are inappropriately accommodated
in hospital beds for extended periods.
Social security where there is a need to reduce barriers to consumer engagement and
communication, to undertake training to assist staff to recognise mental illness and to create an
environment in which clients are comfortable disclosing a mental illness.
Immigration detention processes to protect against wrongful detention of Australian citizens.
Veteranʼs program administration, which requires improvement.
Child protection services and children at risk: Better targeted mental health and risk assessment,
more timely access to therapy, better care planning, improved training, and improved interagency
cooperation is required for children requiring child protection.
Restraint through taser use: Although overall taser use was reviewed positively.
One further observation from this review is that all too often there are no reports from the responsible
government departments, or agencies on the implementation, or progress reports, following the statutory
office review. It is abundantly clear that the accountability requirements on governments, Ministers,
departments and agencies are inadequate given the frequent reoccurrences of the same
recommendations. Repeatedly, statutory authorities are finding the same systemic problems.
In summary, the key themes to emerge from this systematic review are:
Consumers currently have inadequate access to mental health services across the health care
spectrum ranging from prevention to recovery.
Care for consumers is frequently compromised by inadequate interagency cooperation.
Quality supported accommodation is inadequate.
Consumers are not always treated with dignity and respect and in some instances subject to
discrimination.
There are gaps in the training of mental health, health and non-health staff providing services to
people with a mental illness.
There is a need to improve data collection and service monitoring.
Groups have particular unmet needs, including those in the forensic/justice system, those in rural
regions, young people, people of Indigenous heritage or from culturally and linguistically diverse
backgrounds and children at risk.
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4.3 The community surveys
The method
Two community surveys were conducted during April and May 2013 to gather the views of the sector
(providers, consumers, carers, family members and other interested stakeholders) regarding experiences
with mental health services. We wanted to particularly focus on experiences of mental health service or
care in the past 12 months. The community surveys replicated the same surveys conducted by the
Mental Health Council of Australia (MHCA) and the Brain & Mind Research Institute (BMRI) in 200416.
Again in association with the BMRI, ConNetica replicated these surveys in order to review mental health
services in Australia at present and to compare how national and community priorities and experiences of
care have changed since 2004.
This first survey (Community Review of Mental Health Services in Australia) evaluated the extent to which
national and community priorities have been implemented at the local, regional and state/ territory level.
It asked the respondent to rate how the national and community priorities have been implemented or
supported within their local area and then how the national and community priorities have been
implemented or supported at a state/territory level. The second survey (Consumers and Carers Direct
Experiences of Mental Health Care in Australia) assessed direct experiences of care against
internationally developed benchmarks for quality health care. It asked the respondents about their
experiences with mental health services as well as some demographic information. For those
respondents who identified as consumers, it then asked more specific questions about their experiences
with mental health services.
The two surveys were predominantly conducted online and constructed in LimeSurvey and then securely
hosted by the BMRI on The University of Sydneyʼs server. This study had institutional ethics committee
approval from The University of Sydney Human Research Ethics Committee.
The findings
Results of Survey 1: Community review of mental health services in Australia
A total of 477 surveys were received with 86% from individuals and 14% from organisations. The majority
of respondents described their role in the mental health sector as consumer of mental health services
(31%), followed by non-government community service providers (19%), public providers of specialist
treatment (11%) and carers (11%).
First, respondents rated the extent to which national priorities have been implemented or supported in
their local area. Of the priorities surveyed, respondents indicated that a total of 60% were currently not as
implemented or supported as they were in 2004. That is, respondents rated the implementation and/or
support lower than in 2004. Most importantly, these included “provision of early intervention services”,
“genuine consumer participation”, “genuine carer participation” and “clear accountability for expenditure of
mental health strategy funds”.
Next, respondents rated the extent to which priorities have been implemented or supported within their
state/territory. Again, results for all respondents indicated that 75% of priorities were currently not as
implemented or supported as well they were in 2004. These included “development of specific inter-
governmental service agreements”, “direct support for ʻinnovationʼ, ʻresearchʼ and ʻservice evaluationʼ in
mental health”, “support for enhanced role of non-government organisations in all aspects of care”, “clear
accountability for expenditure of mental health strategy funds” and “development of datasets for
monitoring the quality of local services”.
16 Mental Health Council of Australia 2005. Not For Service: Experiences of Injustice and Despair in Mental Health Care in Australia, Canberra.
Summary Report
24
Results of Survey 2: Consumers and carers direct experiences of mental health care in Australia
A total of 561 surveys were received with 87% being from people who had received treatment (directly or
indirectly) in the previous 12 months. Of these, 64% were from consumers, 14% were from carers, 18%
were from family members or close friends, and 4% were from other sources. Forty-three per cent of
those who had received treatment (directly or indirectly) had contact with private health services, 29%
with public health services, and the remaining 28% a mixture of the two.
Key results were:
More than two thirds of respondents (mostly consumers) reported that they were treated with dignity
ʻnearly alwaysʼ or ʻalwaysʼ (69%).
Less than half (43%) of respondents felt that they were able to access adequate services for their
mental health problem ʻalwaysʼ or ʻnearly alwaysʼ. However, the results were more favourable for
consumers (48% of consumers felt they were able to access adequate services alwaysʼ or ʻnearly
alwaysʼ compared with only 29% of carers and 28% of family or close friends).
The majority of respondents (86%) were able to find a health professional to talk about their concerns.
Further:
Most respondents (70%) felt that they were given the ʻright amountʼ or at least ʻsomeʼ information
about their condition or treatment.
Of those respondents who wanted information given to family and friends, more than half (54%) felt
that not enough information was given.
In situations where medication was prescribed for the mental health problem, 55% responded that the
purpose, benefits and side effects were fully explained.
Thirty per cent said that the health professionals involved agreed ʻalwaysʼ or ʻnearly alwaysʼ with one
another. Fourteen per cent reported that the health professionals ʻneverʼ agreed with one another.
Thirty per cent of respondents did not feel they had enough say in decisions about care and
treatment. However, a higher proportion of consumers (78%) felt that they had adequate say in
decisions about care and treatment than carers (48%) or family/close friends (38%).
One in five respondents had not had their diagnosis discussed with them. However, the results were
more favourable for consumers (15% of consumers had not had the diagnosis discussed with them
compared with 33% of carers and 30% of family members).
When comparing data from this survey with that from the same survey run in 2004, the results show there
has been significant improvements in three domains:
1. The extent to which they were able to access adequate services (28% were not able to access
adequate services in the current survey compared with 39% in 2004).
2. The information people are given about their condition or treatment (44% of respondents felt they
were given the right amount of information in the current study compared to only 32% in 2004).
3. Decisions about care and treatment (70% felt they had enough say in decisions in the current study
compared to 62% in 2004).
Consumers then answered more detailed questions regarding their care and treatment. The majority had
seen a general practitioner (98%), psychologist (60%), and/or psychiatrist (62%) in the previous 12
months. Fewer consumers had seen a mental health nurse (25%), social worker (15%) or other mental
health professional (22%) in the previous 12 months. A number of consumers reported they had no trust
or confidence in the social worker (37%), mental health nurse (27%) or psychiatrist (20%). Most
consumers (88%) had taken medications for mental health problems in the last 12 months and 71% had
received a talking therapy. Close to half of the consumers had an afterhours contact in a mental health
service, and of these people 40% had used this form of crisis care in the previous 12 months.
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As with any survey of this type, care needs to be taken when comparing the results from the earlier
survey – while the 2013 sample size was considerably greater than the 2004 study, the gender and
locality information was remarkably similar. This similarity in demographics gives more confidence to any
assertion that the results do reflect an overall improvement in the three domains regarding access to
adequate services, provision of information and decisions about care and treatment.
Notwithstanding this result, a larger representative sample of consumer, carer and provider experiences
of service is required routinely for one to be confident the results are a true reflection of improvements in
service experience.
4.4 The thematic analysis of the Perspectives Essays
To facilitate diversity and depth of input, consumers, carers (paid and unpaid), front-line professionals,
political leaders, former bureaucrats, provider organisations leaders, media professionals, researchers
and policy advisors from a range of settings were identified as potential contributors to this Report.
The method
A diverse group of individuals was invited to contribute a 1000–2000 word written perspective piece. A
staged purposive approach was used to ʻrecruitʼ contributors from February to late May 2013. An initial
list of 130 individuals and organisational leaders were identified using a matrix of settings and expertise
with a further 120 individuals and organisations added to ensure there were sufficient numbers of
contributors and adequate diversity of perspectives.
Partner organisations and individuals identified as potential perspective contributors were sent an
overview of the project and a brief outline stating that the report was going to examine mental health
reform in Australia with particular focus on three key areas:
1. What has been the journey of reform to date since David Richmond and Brian Burdekin's reports 30
and 20 years ago respectively?
2. Where are we now – what is the contemporary experience of care?
3. What should be the future – is there a better way?
Contributors were given freedom to write on either all three key areas or one or two of their choice. All
perspective essays were loaded into a qualitative data analysis tool – hyperResearch. Investigator
triangulation, (i.e. the use of several different researchers to interpret a set of data) was utilised to
evaluate and analyse the majority of perspectives.
The findings
A rich pool of perspectives
The eighty-one Perspective Essays contained within the Obsessive Hope Disorder Report are an
incredibly rich pool of experiences and analyses spanning the last thirty years. The authors include some
eminent Australians who have served in some of
the most important roles in our society. Other
contributions come from professionals with
decades of experience in mental health services in
almost every setting.
There are ʻlived experienceʼ perspectives on the
current mental health care system from those who
are using mental health care services in 2013.
Some of their stories are distressing, pointing to
the continuing systemic issues identified in the
statutory authority reports, other data presented in
the Technical Report, and the need to rethink
Yet, in fact, we donʼt have a ʻmental health
systemʼ. We have a complex mix of
services and programs, which are
unevenly distributed, and sometimes
missing when and where they are most
needed. Overall, our efforts remain
ineffective or too small to meet the vast
need.
Dawn OʼNeil AM
Summary Report
26
efforts on reform. Other stories, however, are reassuring, demonstrating that some real improvements
have occurred in the way people get help for their illness and that reforms have occurred.
Many of the authors are not ʻinʼ the mental health system and bring an observer or participant observer17
perspective. Others have been front and centre of the government policy making and stewardship
processes over the past two decades. Almost all of them identify the structural and political barriers and
challenges to reform and why itʼs just so hard to achieve real national reform for consumers and families.
A number of the authors come from roles as lawmakers and custodians, drawing attention to the ongoing
discrimination and failure of present laws to protect some of those with mental illness. Others have lead
major inquiries into aspects of mental health care and human rights.
There are four perspectives specifically addressing mental health and Aboriginal and Torres Strait
Islander peoples. The authors all ask in their own way if we are focused on the right issues to improve
indigenous mental wellbeing. Other authors detail the journey, the present and the future for lesbian
gay, bisexual, transgender and intersex (LGBTI) communities and there are those that draw our
attention to the issues confronting Australians living in rural and remote communities with
mental health needs and how we can better met their needs.
In a year which has seen the commencement of the Royal Commission into sexual abuse of
childhood in institutions, there is another essay highlighting the need for mental health services
to recognise and be sensitive to the very high rates of sexual abuse suffered by people with
mental illnesses.
Importantly, there are many contributions about what a 21st Century mental health care system looks like
and what we need to do to bring about reform within a decade – from a systems level down to models of
service, to service delivery and own individual attitudes and practices. A number of authors outline the
potential of new technologies to reach more people, reach them earlier and at relatively low cost. And as
it has been almost a constant theme for
decades, many authors stress the need to get
beyond the rhetoric on early mental health
promotion, prevention and early intervention.
There are also international perspectives that
draw on decades of experience working in the
UK and New Zealand and elsewhere, and
identify the key elements missing in our reform
efforts in Australia. In particular, these authors
draw attention to the need for investment in a
national workforce strategy, culture change and
capability development.
There are also some unique perspectives –
most notably that from the ACT Chief Minister
and Health Minister Katy Gallagher. Katy
Gallagher is Australiaʼs longest serving Health
Minister in office. During her six year tenure as
Health Minister, the ACT Government, with the support of the ACT Greens, has developed and
implemented fundamental reform of the ACT mental health care services, particularly focusing on the
establishment of a range of community-based alternatives to hospitalisation. This is not the first time an
Australian jurisdiction has worked to reform its mental health services. Victoria was a leader under the
First National Mental Health Plan in the mid-1990s. The issue is not that genuine reform of mental health
care is too hard; it is that it is too rare.
17 ‘Participant observer’ is a form of sociological research methodology in which the researcher takes on a role in the social situation under
observation. The researcher is immersed in the social setting under study, getting to know key actors in that location, adapted from Pearson Education
2005: http://wps.pearsoned.co.uk/ema_uk_he_plummer_sociology_3/40/10342/2647687.cw/content/
While good policy abounds, there is an
apparent lack of an evidence-based and
recovery oriented model of care or service
framework for community mental health,
making effective implementation of any
policy difficult as well as creating variability
and lack of standardisation at all levels of
the system. In this context, without clear
articulation of a community-based model of
care and despite the fact that the vast
majority of consumers and their families
live in the community, the centre of gravity
for mental health care provision defaults to
the hospital.
Paul OʼHalloran and Dr Nick OʼConnor
Obsessive Hope Disorder
ConNetica 27
Finally there are many perspectives from our Project Partners who provide services in a range of settings
and for specific populations – children, young people, culturally and linguistically diverse (CALD) groups,
people living in rural and remote areas, workplace settings, employment and housing services, helplines
and online platforms, research, primary care, specialist care and community care. Together they
represent the diversity of the mental health sector. Together they have highlighted many service
innovations and structural reforms, which are reflected in the Manifesto for Change in this Report.
We deliberately set out to garner a diverse range of experiences and perspectives in undertaking this
aspect of the project. We also gave minimal direction to the authors who agreed to undertake the
assignment. In that way, it is their reflection and not our construction. The result is an anthology or
encyclopaedia – a set of precious insights into mental health in contemporary Australia. It is difficult and
perhaps inappropriate to attempt to distil these rich contributions to just a few themes and issues.
Nonetheless for the reader short on time, and to add to the other findings, we have attempted this.
Perhaps the one key message from all contributors is that their hope for real reform of mental health care
in Australia is undiminished.
Key themes
There are several key themes evident in the perspective essays relating to challenges and problems
confronting mental health in Australia.
While many contributors acknowledge important progress, the vast majority agree that in terms of mental
health reform, Australia still has a long way to go.
The collection of Perspectives documents many continuing manifestations of stigma, discrimination and
inequity. People with mental illness still
face real problems in relation to their
human rights.
There are still far too many stories
included which document service failure
at a systemic level, with people either
being unable to access the right care at
the right time or finding poor quality of
care. There remain large service gaps
and high levels of unmet need.
Many contributors sheet home this enduring systemic failure to a continuing lack of funding. The
overall health budget continues to increase at a faster rate than the mental health budget, meaning
mental healthʼs share of funding is in decline, exacerbating the disparity between the resources available
and the burden of disease.
In this highly pressured environment, several contributors highlight what they feel to have been a chronic
lack of support for, indeed neglect of, our workforce.
Several authors highlight that this situation has arisen in an environment in which mental health could be
characterised outcome blind, lacking meaningful data, particularly outcome measures.
The persistence of stigma not just in the community
generally but also in the minds of those who are ill
and needing treatment. In fact it can become the
major barrier for people who need to present
themselves for treatment
Professor Geoff Gallop AC, University of Sydney
Despite dozens of plans and policies, reports, inquiries and mental health commissions, spending
between jurisdictions continues to be uncoordinated, lacking both accountability and a focus on
patientsʼ needs. It is impossible to verify whether jurisdictions really do spend what they commit or
what they report. Given the huge burden of mental illness and the unmet needs for mental health
services, proper accountability for this expenditure is crucial to ensure that it is targeted at the areas
of greatest need and is delivering better outcomes for people with mental illness.
Dr Lesley Russell, ANU
Summary Report
28
A recurring theme across the essays is the need for better accountability at all levels, permitting quality
improvement feedback for service providers and reassurance to the community at large that it has a
mental health system on which it can rely.
Other issues
Beyond these key themes, the contributing authors commonly refer to other issues.
Many refer to the fact that the evidence about what was required twenty, and even thirty years ago, has
not fundamentally changed. Over time, many point to successful programs or services that have been
built and piloted across Australia to deliver new mental health services. The common theme here is that
all too often there has been a failure to build these services to scale to meet community needs.
There is a genuine frustration expressed by many contributors regarding the continuing rhetoric–
reality gap on promotion, prevention and early intervention. They lament our continued emphasis on
late stage or crisis intervention, with the mental health system only kicking into action once a person is
already severely unwell and possibly a danger to themselves or others. Equally, the lack of attention to
the physical health needs of people with mental illness is another illustration of a lack of whole-person
care.
People working in the system report how challenging it can be to attempt to re-gear the system, how
complex this kind of change can be at the organisational level.
There are several essays which highlight policy barriers to employment for people with a mental illness.
Other contributors highlight the need to address the social determinants of mental illness more broadly.
This is particularly the case if we are to have any meaningful positive impact on the social and emotional
wellbeing of Aboriginal and Torres Strait islander peoples.
And there were some issues that lay outside this mix of ʻcommonʼ themes. For example, Stephen
Mugfordʼs challenge on the way progress is viewed and indeed the vagaries of mental health definitions
remains a highly contested area and that in a time of apparent resource scarcity, mental health initiatives
may continue to struggle to gain funding.
Several contributors highlight themes or strategies which together, represent a way forward, a better way
for both future reform efforts and how we conceptualise mental health.
Several of these refer to important employment policy and programs based on international and
Australian evidence. Others refer to the importance of systems thinking around the concept of integrated
care rather than focusing just on individual services or providers. Other essays highlight the role to be
played by community education, community prevention activities and local planning.
Many contributions call for greater
consumer, carer and peer worker
participation in co-design, management
and monitoring of mental health systems
and care. New opportunities to apply
technology to assist in more timely,
effective and contiguous mental health
care are also identified.
From the thematic analysis we have
postulated a number of ʻtheoriesʼ relating to the journey of mental health reform and the ʻdriversʼ for the
failure of policy implementation so consistently expressed in the perspective essays. Most see this failure
as being the result of inadequate planning, definition and detail. Too often high falutinʼ reform rhetoric is
not matched with concrete implementation. Part of this is about disaggregated and ineffective
governance structures, weak stewardship of the process and surely another factor, as pointed out in
several essays, relates to inadequate funding to support reform. Real funding is all too difficult to
Let us hope that the next thirty years of mental health
reform will be informed more fully by the voices of
experience, consumers and families and that services
will be more fully engaged with consumer and carer
peer support programs.
Joe Calleja, CEO Richmond Fellowship WA
Obsessive Hope Disorder
ConNetica 29
determine from the “funny money”18, re-labeled and/or re-announced funding that is evident from too
many governments. Many authors also make reference to the complexity of funding and service
arrangements and the consequent deleterious impact these have on the quality of care available.
There is also inconsistent access and quality of care, partly the result of the failure to define a national
service framework and national models of service. Contributors also point to the neglect of the mental
health workforce over decades.
Finally, a key driver of mental health reform failure is clearly poor accountability – not being able to tell
whether what we are doing is really making any difference to peopleʼs lives.
Figure 4: Key themes and drivers: A postulated theory on Australiaʼs mental health “reform gap”
4.5 The commissioned and specific topic analyses
The mental health workforce
The mental health workforce has been a central player in the journey of reform. This analysis was
undertaken as a ʻspecial interest topicʼ based on the preliminary project scoping which continually
identified the neglect of the workforce as an obstacle to reform.
The history of the mental health workforce shows that in spite of all the change, the remnants of the past
remain within the mental health system. Given the tragic history and treatment of the ʻinsaneʼ it is little
wonder that the vast majority of mental health consumers, families and professionals want to move as
physically far from the old asylums, and to a lesser extent, the new mainstreamed hospital services as
possible.
18 Dr Lesley Russell coined this term in media interviews following the 2011 Federal Budget when discussing mental health funding.
Summary Report
30
For the workforce the journey has clearly been a wild ride with far too little support and too little attention
to much of what David Richmond recommended. If implemented, the Richmond Reportʼs
recommendations would have eased the workforceʼs journey from custodial care practices and ordered
environments, to moving to practice in contested and open environments, to take on new paradigms of
care and to view themselves as part of a national picture in the knowledge era.
A number of themes identified in the historical analysis continue to be evident in the mental health
workforce of 2013: federalism continues is an ever-present backdrop; the taxonomy of staff has
broadened, and their roles are identified; the location of the workforce has changed and the type of
practices they engage in varies across the sector; workforce culture impacts across the system; and three
issues continue to plague administrators – staff recruitment, retention and efficient utilisation.
In spite of the best intentions of government and significant investment there seems to have been only
limited and patchy improvement in workforce capacity, capability, deployment and sustainability.
Recurring patterns of problems in organisations and even industries may signal embedded processes,
which are often unconscious to the parties involved and difficult to change. This appears to be the case
in mental health. Breaking this cycle of recurring patterns observed in the mental health workforce for the
past 30 years is addressed through a systems approach.
What is clear from numerous reports is we know what to do; the problem again has been policy
deployment. Without diverting attention away from the mantra of recent years, attention needs also to be
directed to what, at the risk of using a mechanical metaphor in an organic era, is the ʻsystem toolboxʼ
required to make the change happen – in this case a more modest ʻstarter kitʼ.
A number of suggestions for change are offered as a means to break the embedded patterns which seem
to cause major change inertia: these mainly relate to culture, planning, information for pro-activity,
standards, shared competence, leadership and change management.
Governance and accountability
Another of the special topics to be included in the analysis of the state of mental health services is
governance and accountability. Like workforce, the issue of governance and accountability was
consistently reported as a requirement and an implementation problem evident in the preliminary scoping
for this project.
In relation to governance and accountability in mental health, Australia has always talked a good game.
We have the neatly articulated plans to prove it. What has been lacking is the willingness to invest in
genuine, regular, independent processes of monitoring and assessment of progress towards mental
health reform. At the heart of this must be the validated voice of the consumer and carer providing a true
picture of the impact of mental illness on their lives.
One of Australiaʼs most significant achievements, again made possible under the First National Mental
Health Plan in 1996, was the establishment of a set of National Mental Health Service Standards. These
Standards led the world in laying down markers against which to assess the quality of care provided,
giving both service providers and users much clearer expectations. Again due to lack of resources, these
Standards, while widely respected, were never really implemented or monitored. In 2010 they were
reviewed but again, no resources to enable their effective implementation or monitoring have been
allocated. Even more recently, a new recovery standard was developed and issued in 2012 but again no
resources were allocated for training or implementation. Fine words again resting on hope as a
deployment strategy.
Important for mental health reform are the broader reforms to health and hospital reform. Part of
Australiaʼs recent health reforms has involved rearranging financial relationships between the states and
the Commonwealth governments. It is precisely in the area of most concern to mental health reformers;
that part of the service system which aims to avoid hospitalisation and provide as many services as
possible designed to keep people living well in the community, where responsibility between the federal
Obsessive Hope Disorder
ConNetica 31
government and the states is most unclear. This is the dilemma that lies at the heart of Australiaʼs
governance problems.
Genuine reform mental health in Australia must start with a new commitment and real resources to enable
better governance and accountability. The issue is too important and too expensive for us to remain
ʻoutcome blindʼ.
Special populations and mental health issues
When the National Health and Hospitals Reform Commission handed its report to the Rudd Government
in July 200919, it made the point that the immediate priorities for reform action were in relation to services
for people in rural and remote Australia, Indigenous Australians, those with chronic dental health needs
and those with mental health needs. As one Commissioner20 summed up things ʻif you were an
indigenous person living in remote Australia then prospects for any care are not good. If you needed
mental health or dental health care, forget itʼ.
In the analysis presented in Obsessive Hope Disorder, it is very clear that special populations – people
from culturally and linguistically diverse (CALD) backgrounds, Aboriginal and Torres Strait Islander
peoples, people living in rural and remote Australia, young people, LGBTI people and those with
comorbidities such as deafness or an intellectual disability – were all under-served by both mental health
policies and programs. All too often it was clear that the ʻmental health policy caravanʼ had really not
stopped to address neither these population groups nor their needs beyond a ʻcomfort stopʼ.
It was beyond the scope of this crowdfunded Report to address each of these groups needs and map out
a “better way” for the future. One group was selected as a case approach to tackling the needs and
providing a way forward – those people from a culturally and linguistically diverse background and the
multicultural mental health issues in Australia.
Drivers for reform in this area include the fact that Australia has for the past 50 years been a diverse
nation and we are continuing to grow in our diversity. Serious gaps already exist in terms of the
accessibility of mental health services for Australiaʼs culturally and linguistically diverse populations.
Policy, planning and implementation of mental health services cannot ignore this reality.
There are several issues identified in the analysis in relation to CALD peoples and mental illness:
Poor access to timely and culturally appropriate care.
Poor understanding of the extent of the needs – not only are we “outcome blind” but also “needs
blind” as well.
The need to improve the quality and safety of communications between CALD consumers and mental
health practitioners.
Improving access to services requires working with CALD communities to reduce shame and stigma.
Improving the access, quality and safety of services for CALD populations requires a whole-of-service
organisation approach.
19 National Health and Hospitals Reform Commission 2009.A Healthier Future for All Australians. Final Report. Australian Government, Canberra.
20 Personal communications of a Commissioner to Chair of the National Advisory Council on Mental Health, 2009
Summary Report
32
Addressing these gaps and planning for Australiaʼs future requires investment and action in the mental
health system. Specifically, we need investment and action to:
Improve our understanding of the extent of the problem with regards to prevalence and access in
relation to CALD communities.
Improve the safety and quality of communications between CALD consumers and mental health
practitioners.
Reduce the shame and stigma around mental illness and improve mental health literacy in CALD
communities.
Improve the cultural responsiveness of Australiaʼs mental health system through whole-of-
organisation and whole-of-system approaches.
Mental health research
The Black Dog Institute at the University of New South Wales has undertaken a review of mental health
research for the Obsessive Hope Disorder Report.
Research in mental health is a critical activity. Without research, the causes of disorders will never be
understood. Without research, the effectiveness of new treatments, better health service methods, and
new methods to aid recovery will not be forthcoming. Importantly, research forms the basis on which we
can reject service models, treatments and programs that are not effective, non-evidence-based, or even
harmful. In other words, research tells us on the basis of “effectiveness” which approaches to jettison and
which ones to embrace.
Mental health research is one of the key opportunities for achieving breakthroughs in both novel
treatments and service innovation. Again, the efforts to date have been mediocre at best and mental
health research stays stuck in the slow lane. Despite much ʻnoiseʼ there is little evidence of any increase
in the allocation of funding for mental health research. Mental health research when compared with other
health areas continues to receive an inequitable share of the cake.
In relation to priorities, the evidence shows a considerable discrepancy between stakeholder priorities and
the research that is currently being undertaken and funded. While there was significant publication and
funding related to affective disorders in line with priorities, there were clear gaps in research on
schizophrenia/psychosis, childhood conditions and suicide. In particular, childhood conditions and suicide
received little funding, despite their high priority in the stakeholder rankings. A disproportionate amount of
funding and publications goes to substance use disorders compared to their relatively lower ranking in
stakeholder priorities.
Although affective disorders now receive a level of funding that is in line with disease burden, current
publication output does not yet reflect this. Other disorders that appear to be adequately funded and
researched in harmony with degree of disease burden include eating disorders, substance use disorders
and schizophrenia and psychosis. However, it appears that there are marked discrepancies between the
limited degree of funding and publication output in anxiety disorders, dementia and in particular,
personality disorders and suicide, when considering their considerable contribution to burden of disease
associated with mental disorders.
In summary, the data reveals that research output is inconsistent with the “burden of disease”. Dementia,
anxiety and affective disorders and suicide are all underrepresented in Australian-authored publications,
relative to their significant disease burden and costs to society.
The remedies are not rocket science. The return on the investment for Australia: potentially enormous.
Obsessive Hope Disorder
ConNetica 33
New initiatives to align research with national priorities and to embed research within health services may
increase health service research21. The development of health research and service hubs, as
recommended by the 2012 Wills Review22, has the potential to accelerate the growth of a more vibrant
clinical research agenda. If successful, embedding research into service reform will be likely to increase
health services research and accelerate health reform, and increase accountability.
A focus on translational research may increase the types of groups who are served by the research
targets and ensure the implementation of new treatments and procedures will become a focus of
research. The growth and development of philanthropy in Australia might be a consideration. More
philanthropic grants to mental health research will grow the base. The type of research will be changed if
philanthropists focus on specific health topics within psychiatry and mental health.
The power of the consumer voice may grow and directly and indirectly influence what topics and settings
are covered. Advocacy for research might lead to increases in some research areas.
Hopefully, priority-driven research, translational research and research conducted within and around
health systems will lead to increased creativity and research that is more responsive to priorities.
Assessing the state of mental health in Australia
In scoping the project, it was clear we needed to assess the overall system. The other methods selected
for this project zeroed in through particular pathways. A whole-of-system approach was also necessary.
The research team set out to answer some basic questions, namely:
What is the prevalence of mental health problems and illnesses in Australia?
What do we know about the health of people with mental illnesses?
How well are services responding to mental health needs of Australians?
What is the current state of mental health services in Australia?
How many Australiansʼ have access to care?
What is the quality of that care?
What is the level of awareness and understanding of mental health and illness in the Australian
community?
What are the outcomes achieved from these services?
What reforms have been implemented by the Australian Government since 2006 to respond to
widespread concern about mental health services?
Prevalence
Mental illness is one of the most prevalent conditions affecting the Australian population and, according to
the most recent National Survey of Mental Health and Wellbeing23 (SMHWB) released by the Australian
Bureau of Statistics (ABS), around 45% of Australian adults will experience a mental illness at some time
in their life. One in five people reported experiencing symptoms in the 12 months prior to the survey and
a further 25.5% of adults had experienced a mental illness at some time in their life, but did not have
symptoms in the 12 months before the survey.
Up to 3.2 million adult Australians, nearly 16 per cent of the entire population, are either permanently or
transiently affected by depression or other mental illnesses during any twelve month period and over half
of them are not responding to standard treatments. The true rate of mental illness in Australia will be
higher than the above figures in view of dementia and less common mental disorders (e.g. schizophrenia
21 McKeon Strategic Review of Health and Medical Research 2013. Strategic Review of Health and Medical Research – Better Health through
Research – Final Report. Australian Government Department of Health and Ageing: Canberra. ISBN: 978-0-9872039-5-3. Available at
www.mckeonreview.org.au/downloads/Strategic_Review_of_Health_and_Medical_Research_Feb_2013-Final_Report.pdf (accessed 30/5/13)
22 Wills Review 2012. NSW Health and Medical Research Strategic Review. NSW Ministry of Health: North Sydney. Available at
www.health.nsw.gov.au/pubs/2012/pdf/medical_strategic_review_.pdf (accessed on 31/5/13).
23 Australian Bureau of Statistics 2008. National Survey of Mental Health and Wellbeing. Canberra, October 2008.
Summary Report
34
and other psychotic disorders) being excluded from the national survey. The overall prevalence rates
have changed little between 1997 and 2007.
There is some evidence to show that rates of major depression have increased in Australia24 have
increased however it is more generally believed that rates on severe mental illness (major depression,
severe anxiety, psychoses) have not changed and remain at around 3–4% of the adult population.
The proportion of Australians experiencing mild to moderate illnesses has remained relatively stable over
the past three National Health Surveys, however the prevalence of particular categories of disorders has
changed25.
The prevalence rate of Australians experiencing a mental illness significantly exceeds diabetes (4% of
adults) and cancer (2.5% of adults). Importantly the prevalence of severe mental illness exceeds that of
all cancers combined.
The highest prevalence rates for mental health conditions occurs from late adolescence until later mid-life
years (16–54 years) with the peak rates (nearly 1 in 3 people) in the 16–24 year age groups. The most
prevalent disorders are anxiety, depression and substances abuse disorders – these are referred to as
high prevalence disorders.
According to The burden of disease and injury in Australia 2003 (AIHW 2007), mental illnesses (including
suicide) were estimated to be responsible for 15.3% of the total burden of disease in Australia in 2003.
Mental illness is also the largest single cause of disability, contributing to 24 per cent of the burden of
non-fatal disease. Around 600,000 Australians experience severe mental illness and an estimated
60,00026 have ʻenduring and disabling symptoms with complex and multi-agency service needsʼ.
The health and wellbeing of people with mental illnesses
Presently in Australia we do not have access to routine health data about people with mental illness. We
rely therefore on a patchwork of data sets to build a picture of the overall health and wellbeing of people
with mental illness. What this patchwork of data tells us makes for stark reading. People with mental
illnesses experience: higher death rates (2.5 times the general population); higher rates of diabetes and
obesity, heart disease27 and some cancers; much higher rates of tobacco use (nearly three times the rate
of the overall population); higher rates of poverty, unemployment, social exclusion, and homelessness;
higher rates of imprisonment and violence (more often as victims); and a 16–25 year reduced life
expectancy which appears unchanged in a century28 29.
Mental illness is the largest single cause of disability, contributing to 24% of the burden of non-fatal
disease. This is over 3.5 times the disability burden of all cancers. Mental illnesses were estimated to be
responsible for 15.3% of the total burden of disease in Australia in 200330.
Moreover, diseases of the brain and mind (including neurological conditions such as autism spectrum
disorders and dementias) now account for more than 45% of all illnesses. These diseases are
devastating for those affected, their families and for society, and the cost to the Australian economy has
recently been estimated to be in excess of $190 billion a year31. These costs are expected to grow
substantially over the next forty years. Dementias alone are predicted to more than treble from around
330,000 cases today to over a million cases by 2050.
24 Goldney R Hawthorne G Taylor A 2010. Changes in the prevalence of major depression in an Australian community sample between 1998 and
2008. ANZ J of Psy. 44: 10 901-910.
25 Medibank Private Limited & Nous Group 2013. The Case for Mental Health Reform in Australia: a Review of Expenditure and System Design.
26 This figure of 60,000 and the definition is given by the Department of Health Ageing in several documents and based on an unpublished report by
Harvey Whiteford and Bill Buckingham (2006 and 2011).
27 Goldston K Baillie A 2008. Depression and coronary heart disease: a review of the epidemiological evidence, explanatory mechanisms and
management approaches. Clin Psych Review, 28: 289-307.
28 Coghlan R Lawrence D Holman D Jablensky A 2001. Duty to care: Physical Illness in People with Mental Illness. Perth University of WA.
29 Lawrence D Hancock KJ Kisely S 2013. The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia:
retrospective analysis of population based registers, BMJ 2013;346:f2539, 21 May.
30 Australian Institute of Health and Welfare 2007. The burden of disease and injury in Australia 2003.
31 Lancy A Gruen N 2013. Constructing the Herald-Lateral Economics Index of Australia’s Wellbeing.
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ConNetica 35
Much of the economic cost of mental illness is in terms of productivity – time out of employment,
education and training either due to illness or caring for some affected by a mental illness. The recent
report from the Inspire Foundation32 showed that the cost of mental illness among young men alone (16–
24 years of age) was a staggering $389,000 per hour, 24 days a day, 365 days a year – equivalent to the
cost of an outer suburban house or a CBD apartment every hour.
For adults:
Life expectancy is between 16–25 years lower, depending on the mental illness. Those with
psychoses have the lowest life expectancy and it appears this has not changed for decades.
Ninety per cent of people with a mental illness have a least one other chronic health condition.
The rate of obesity is between 55–70% higher than the general population.
The rate of cardiovascular diseases are 2 to 3 times the general population.
The rate of stoke is 130% higher than the general population.
The rate of asthma is estimated to be 50% higher than the general population.
The rate of diabetes is reported to be three times that of the general population.
Musculoskeletal conditions are estimated to be twice the rate of the general population.
For women who are exposed to repeated violence, nearly 90% develop mental illnesses.
Lower socioeconomic status is both a risk factor and a consequence of mental illness.
For young people:
The 12-month prevalence of mental illness is more than one in four young people (28%).
Suicide is leading cause of death for people over 16–25 – nearly one in every four deaths.
In every Year 12 class in Australia, on average, there will be one student who has attempted suicide.
Two per cent of young men report a suicide attempt in the previous twelve months.
Nearly 20% of young men report that ʻlife is not worth livingʼ.
Nearly four out of ten young people binge drink regularly.
For children:
Fourteen per cent of children are affected with developmental disorders and the majority are not
identified or treated appropriately.
One in 110 children has autism spectrum disorders.
Over 250,000 child abuse notifications are received annually in Australia and appropriately 50,000
cases are substantiated. (Child abuse is the strongest predictor of mental health problems and
suicidal behaviour in later life.)
Figure 5 illustrates some of the health status data of children, young people and adults with mental
illnesses and developmental disorders.
32 Inspire Foundation 2012. The cost of young men’s mental illness.
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36
Figure 5: People with mental illness at life stages: Prevalence rates of physical health conditions
compared with general population
Data sources: These are cited in full in this Report: ABS (2008); AIHW (various); AIFS; AICAFMHA; Autism Australia; Lawrence D et al 2013.
The service response
Despite spending of over $6 billion33 this year on MHS by governments, access to affordable, timely and
effective care is a widespread problem for people with any mental health condition. Over two million
Australians with a clinical condition did not use any service in the previous 12 months.
The quality of mental health care continues to feature in many independent and media reports. While
there is some evidence that the quality of care for people who are known to mental health services has
improved34, around 40% of those people with a severe level of disability from mental illness have little or
no contact with services. For the estimated 700,000 Australians with moderate levels of psychiatric
disability (usually with more than one illness, comorbidity substance abuse, poor physical health, long-
term unemployment or on disability payments and socially excluded) access to services is even poorer
with estimates ranging from 25–30%35.
For people with moderate and severe levels of disability from mental illness, access to coordinated care,
is critical to recovery. This means, health care working hand-in-glove with housing, transport,
employment support, education and training, family support and child support and often with justice and
Police. This is very rarely the case and consequently, an individualʼs problems manifest and multiply and
the road back to wellness, social inclusion and participation is fraught.
33 AIHW 2012
34 Morgan V 2011. People Living with Psychotic Illness 2010. Report on the 2nd National Survey. DOHA, Canberra.
35 Bishop J 2010. Mental Health Services Reform. Presentation to the Mental Health Service Conference (TheMHS) Sydney, August 2010.
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A recent major study examined the appropriateness of care for 22 common health conditions. Three of
the conditions were mental health disorders, namely, panic disorder, depression and alcohol dependence
disorder36. The study examined the appropriateness of care with evidence-based or consensus based
guidelines. Health care providers volunteered for the study and around 50% were GPs, 22.5% specialist
practices and 14.5% hospitals. In general the review found “that the consistent delivery of appropriate
care needs improvement. In the three mental health conditions included in the study almost three out of
every four encounters for panic disorder were in line with guidelines while only 55% of encounters for
depression met guidelines. The care provided for alcohol dependence was appropriate in only 13% of
encounters.
High rates of readmission to acute care (< 28 days), high rates of compulsory treatment orders and high
rates of seclusion and restraint are all associated with poor mental health care and a system under
stress. These are all features of Australiaʼs specialist public mental health care system.
Inadequate funding over decades lies at the heart of Australiaʼs mental health service-need gap. Despite
the increased attention to mental health at the level of COAG since 2006, the percentage of funding for
mental health care is declining as shown here in Figure 3.
The government response since 2006
Prime Minister John Howard and NSW Premier Morris Iemma lead the COAG response in 2006 to the
damming assessments of Australiaʼs mental health system contained in the Mental Health Council of
Australiaʼs Not for Service report and the Australian Senateʼs From Crisis to Community report.
A major feature of the Commonwealthʼs response package ($1.9 billion over 5 years) was the Better
Access Initiative – items under the Medicare Benefit Scheme (MBS) for access to psychiatrists,
psychologists and GPs which committed over $500 million under fee-for-service arrangements. In 2008
the Federal Budget increased the estimated expenditure from $538 to $773.5 million over the 5 years to
2010–1137. This program is now costing around $10m per week to the Federal Government. Growth has
being significantly greater in more affluent areas and metropolitan locations. Debate has been fierce with
critics attacking the ʻbusiness as usualʼ approach under MBS for the Better Access program38.
36 Runciman WB et al. 2012. CareTrack: assessing the appropriateness of health care delivery in Australia. MJA, 197 (2), 100-105.
37 Rosenberg S Hickie I Mendoza J 2009. National mental health reform: less talk, more action, MJA 190: 4, 16 February.
38 Ibid.
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Figure 6: Mental health vs Health spending increases 2006–07 to 2010–11
One of the major programs funded through the Department of Families, Housing, Community Services
and Indigenous Affairs (FaHCSIA) is the Personal Helpers and Mentors (PHaMs) program which aims to
increase opportunities for recovery for people aged 16 years and over who have a severe functional
limitation due to severe mental illness. Eligibility is typically restricted to the around 180 postcode areas
allocated to a PHaMs service provider.
An evaluation of the FaHCSIA Targeted Community Care Mental Health Initiatives, commissioned and
managed by the Department, found that all stakeholders believed PHaMs was an effective initiative, with
high satisfaction levels and support for the recovery model approach. There were concerns about the
number of service providers fragmenting the system, the small size of many service organisations, and
the short-term contracts having a negative impact on clients39.
A brief retrospective on the Rudd–Gillard Governments
The Rudd Government came to power in November 2007 with an ambitious social reform agenda. This
included radical proposals for reforming the health and hospital systems and clear commitments to do
better on mental health. The new Federal Health Minister Nicola Roxon stated in June 2008:
As I outlined prior to the election, we are committed to meaningful reform… In particular, we are
committed to:
Putting mental health firmly on the national agenda, working with states and territories on an
integrated national approach to service delivery
Putting in place an evidencebased approach
Reorienting mental health policy towards prevention and early intervention
Ensuring mental health services are well integrated with other primary care and specialist
services
Investing in programs such as ATAPS to ensure resources are used to fill gaps in existing
service delivery, particularly in rural and remote Australia
Developing an open, transparent system of evaluation and accountability of existing mental
health services
Developing a 10 year plan to address homelessness in Australia, with people with severe
mental illness sadly prominent in our homeless population
Ensuring that people with a mental illness have every opportunity to gain and maintain
meaningful employment without prejudice.
39 Evaluation of the FaHCSIA Targeted Community Care Mental Health Initiatives, http://www.fahcsia.gov.au/our-responsibilities/mental-
health/publications-articles/evaluation-of-the-fahcsia-targeted-community-care-mental-health-initiatives?HTML#B_3, Accessed 29 April 2013.
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However, the only action on mental health of the Rudd Government was to cut funding to some programs,
including the highly effective Mental Health Nurse Incentive Program. Some $300 million was clawed
back from the Forward Estimates in the Budget Papers40.
In response to the chorus of criticism led by key mental health advocates, including the 2010 Australian of
the Year, Professor Patrick McGorry, the Rudd Government included a modest package of some $181
million in new funding for mental health in the 2010 Budget and COAG Health and Hospital Reforms.
This was less than 2% of the overall amount of new funding committed to health reform and the critical
chorus simply amped up. Worse still, when closely examined this was just $31.5 million in real new
funding over four years, the remainder being “funny money” – redirected, re-announced or re-badged. In
real terms, mental healthʼs share of health funding was declining.
The 2010 Federal Election featured mental health policy as a central issue for all the major parties: the
Coalition announced a $1.5 billion package in the campaign focused specifically on key areas of
prevention and early intervention. The Gillard Government responded with a $273 million package
targeting suicide prevention and the clear pledge that “mental health would be a second term priority”.
Prime Minister Gillard stated that mental health would clearly be a “second term priority” for her
government41.
Despite occupying the Treasury benches since November 2007 and the much trumpeted $2.2 billion
mental health package in the 2011 Budget42, it was only in the last few months of 2012 that tangible
progress emerged from decisions made by the Rudd-Gillard Governments on mental health. Finally
additional youth mental health (headspace) services opened43; the number of clients receiving care
through the PHaMs Program increased (up approximately 20%) and there was some belated, limited
expansion of the Access to Applied Psychology Services for people on low incomes.
Consistent with broader narratives on the Rudd-Gillardʼs Government, the two most significant initiatives
announced in both the 2010 and 2011 Federal Budgets, namely the commitment to Early Psychosis
Program centres ($245m) and a new care program for people with severe and persistent mental illness
(i.e. Partners in Recovery at $550m) are yet to deliver a single service to any individual.
Fourth National Mental Health Plan 2009–201444
The 4th Plan states that “Improving accountability for both mental health reform and service delivery are
central to the Fourth Plan”45.
The 4th Plan included several priority areas including, Prevention and early intervention; Service access,
coordination and continuity of care; and Social inclusion and recovery. As with the previous NMHPs there
was little detail in terms of resources, milestones and measures but again a multitude of possible actions
and motherhood statements46.
The 4th Plan did acknowledge that despite increased funding to primary and specialist services, treatment
rates are low compared to prevalence and that service options need to be informed by population
planning specifying the mix and level of services. It also acknowledges that there is a critical need to link
between and within sectors, and achieve service coordination.
However, the 4th Plan reflected the same inadequate approach to the policy so evident in earlier National
Plans.
40 Russell L 2009. What’s New in Mental Health? Report to the National Advisory Council on Mental Health.
41 Mental health a second-term priority, says Gillard, Sydney Morning Herald, 27 July 2010.
42 Of the $2.2 billion, the majority of the funding was re-directed, re-announced or re-badged funds. Independent analysis by Access Economics
showed only some $600 million as additional funding over five years.
43 The Howard Government committed funding for the establishment and ongoing operation of 30 headspace service sites in 2005-6. While the Rudd
Government agreed to increase this to 45 in 2010 and then 90 following the 2010 Election, the 31st headspace service only opened in early 2012.
44 While the NMHP is an inter-governmental agreement, its development is led by and funded by the Commonwealth.
45 Commonwealth of Australia: 2009. Fourth NMHP: An agenda for collaborative government action in mental health 2009-2014.
46 Ibid.
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40
The Roadmap for National Mental Health Reform 2012–2022
The final CoAG meeting in 2012 approved and released the ten-year Roadmap for reform47. The
Roadmap emerged as a policy commitment from the (then) Federal Mental Health Minister, Mark Butler in
late 2011 prior to any consultation with states/territories or CoAG imprimatur. Consequently, ownership
and acceptance of the document as a blueprint for reform by CoAG was somewhat muted:
The Roadmap for National Mental Health Reform is the response of our collective governments to
the challenge put to them by PM Gillard following her investment of $2.2 billion in new and
redirected funds in 2011. As such one would have hoped for a document that clearly defined the
destination, set a timetable for reaching landmarks along the road to the destination, defined key
measures by which substantive change could be assessed, set real targets that were consistent
with our national aspirations and modelled the size of investment that would be necessary to
achieve real change.
Professor Ian Hickie AM, 11 December 2012
The initial reactions to the final document reported in professional commentary48 and national media
reflected a sense of déjà vu of previous government blueprints – fine visionary statements with too little
detail on what, how, when and by whom.
No specific performance measures were set out. Rather the Roadmap includes a preliminary set of
11 indicators and 3 ʻcontextual indicatorsʼ. The task of developing an agreed set of measures has been
sent to the Ministerial Working Group for report back to CoAG at the end of 2013.
In essence, the Roadmap leads us somewhere we have already been for a long time, not somewhere
new.
The National Mental Health Commission
The National Mental Health Commission (NMHC) was established as a policy initiative of the Gillard
Government following the 2010 Election. The development and release of an annual report card was its
principle function. The National Commission is limited in its powers and constrained by being established
as an executive office within the Department of Prime Minister and Cabinet. The NMHC is for all intents
and purposes an advisory body within a central policy department answerable to and directed at will by
the relevant Minister.
National Mental Health Commission Report Card
In November 2012, the NMHC released the much anticipated report card on mental health49. .The Report
A Contributing Life – was given considerable coverage in national media and drew attention to the
failure of reform. However, it simply restated much of what other reports have said for more than a
decade.
The Report points to the lack of any clear, agreed picture of what a good mental health service or model
should look like and does not offer such. The Report Card does not propose any indicators or system of
accountability but simply calls on governments to do so.
Generally while the Report Card has been welcomed by key stakeholders in the mental health sector, it is
seen as ʻbusiness as usualʼ, a largely rear-view mirror perspective on what has been rather than what is
now, as lacking in prevention and promotion and short on discussion on early intervention and young
people. While the NMHC remains in its current form, the Report Card is unlikely to drive national mental
health reform.
47 Council of Australian Governments (2012). The Roadmap for National Mental Health Reform 2012-2022. Available at
http://www.coag.gov.au/sites/default/files/The%20Roadmap%20for%20National%20Mental%20Health%20Reform%202012-2022.pdf.pdf.
48 Rattan, R (2012) Five views of the Roadmap for National Mental Health Reform. The Conversation, 11 December 2012.
49 National Mental Health Commission (2012). A Contributing Life: the 2012 National Report Card on Mental Health and Suicide Prevention. Australian
Government, Canberra.
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For the NMHCʼs Report card to become the game charger that everyone so desperately hopes for,
what is needed is a culture change that sees mental health and wellbeing as a key indicator for the
nation to its citizens50.
In summary – The state of mental health services
What is clear from the available data on the health and social and economic wellbeing of those with
mental illness is that they continue to receive inadequate access to health care and that the health care
received is too often not appropriate or effective. What is also abundantly clear is that the cost of not
providing access to care or quality mental health care is hurting the nationʼs productivity and prosperity.
Mental health services in Australia are neither planned on the basis of need (that is to respond to the
populationʼs mental health needs) nor based on evidence of what works best. There are, in short, serious
structural imbalances51 in the system of care compounded by poor and out-dated practices52.
50 Russell L 2012. On the first national mental health card, the real question is: what happens now? Croakey: the Crikey health blog. Dec 2.
http://blogs.crikey.com.au/croakey/2012/12/02/on-the-first-national-mental-health-report-card-the-real-question-is-what-happens-now/.
51 Doessel D Williams R Whiteford H 2010. Structural imbalance and resource shortage in the Australian mental health sector. J. of Mental Health
Policy and Economics, 13 1: 3-12.
52 Runciman WB et al 2012. Op Cit.
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5. A better way forward
Introduction
Within this report, Obsessive Hope Disorder, we endeavour to tackle some of the critical issues for
achieving the transformation of mental health and mental health care that for so long has eluded us. This
is much more than achieving the vision and goals articulated by David Richmond in 1983, and later
reiterated by Brian Burdekin all those years ago. It is all about ensuring that:
1. People with a mental illness have the same parity of access to and quality of care available to
Australians with other major health conditions regardless of our origins, our income or postcode.
2. The mental health services and care available are based on evidence – not the legacy of history –
and are focused on the earliest intervention and where necessary provide seamless continuity of care
and linkage to social supports to enable full recovery with dignity.
3. Australianʼs understand that being mentally healthy is much more than the absence of a mental
illness and there are actions they can take to sustain and improve their own mental health and the
resilience of their communities.
4. Mental health in Australia is seen and understood in relation to the bigger picture – including the
contribution of mental health and wellbeing to schooling, urban planning, workplace relations, national
productivity and more – mental health is part of the nationʼs mental wealth.
The incremental, incomplete and inconsistent approach to mental health reform over the past twenty
years is demonstrably inadequate and unaffordable for the challenges now confronting our nation.
We can and must do better. To do better we have to accept the baggage from the past, identify the
barriers to reform and map out strategies for change based on these experiences and those from
overseas.
One of most obvious artefacts of Australiaʼs national mental health reform project is that in every state,
except Victoria, we still see stand-alone psychiatric hospitals still operating. These relics of the past in
mental health are still very much defining our present service models, facilities, workforce distribution and
practices, community attitudes, and so on. These relics are barriers to building a truly 21st century model
of mental health services and achieving a mentally healthy Australia for all.
Breaking the bonds with the past requires new thinking and structures which impel the ongoing
commitment of governments and others to the task of reform. It requires us to embrace new approaches
and rid the system of anachronistic services and facilities.
Fix the policy and legal frameworks
In 2009 the World Health Organization (WHO) released guidance documents for the development and
deployment of mental health policy. Improving health systems and services for mental health53 sets out
best practice approaches to developing mental health policy, plans and programs, mental health
legislation, planning and budgeting, human resource management and development of mental health
information systems. Each of these elements are seen as the foundations for effective and sustained
mental health service reform. WHO states:
“By using this strategy as a guide, countries can ensure that their mental health systems are not
haphazard, but rather, the products of careful consideration and planning.”
The WHO documentation also provides a simple and practical ʻchecklistʼ for evaluating each of these
critical elements of ʻinfrastructureʼ.
53 WHO 2009. Improving health systems and services for mental health. WHO Press, Geneva.
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44
A cursory comparative review of the findings documented in Obsessive Hope Disorder and the WHO
checklist highlights many basic failings in the approach taken over the past twenty years in Australia.
Robust frameworks for developing and implementing public policy in relation to health and human service
systems are not novel. Yet this knowledge has not been applied to mental health policy in Australia over
a very long time and there is little evidence from the most recently released planning documents (e.g. The
Roadmap for National Mental Health Reform 2012–2022 released by COAG in December 2012) that this
is changing.
In fact there is some evidence that there have been actions taken at the most senior levels of
bureaucracy to dumb down past mental health planning documents54. It seems the avoidance of real
reform and certainly real accountability, has been a ʻsin of commissionʼ rather than a ʻsin of omissionʼ.
Further, continuing reports55 regarding the human rights abuses of people with mental illnesses and
widespread discrimination, point to the need to get mental health legislation harmonised across Australian
jurisdictions and aligned with international practice.
The rule of law is the basis of Australiaʼs democracy. It seems a good place to start to right the wrongs of
current mental health care.
Figures 7 and 8 contrast the integrated and proportional approach to a system of mental health care
proposed by the WHO and the reality of Australiaʼs array of service elements after twenty years of reform.
5.1 Some relevant public policy developments
DisabilityCare Australia and mental health
DisabilityCare Australia is the new national disability insurance scheme (NDIS). This major reform, which
will be implemented in stages, began on July 1, 2013. DisabilityCare will provide individualised support to
eligible people with permanent and significant disability, including those with a psychosocial disability
associated with a mental illness. It is estimated there are 57,000 Australians with mental illness who
would be eligible for DisabilityCare.
DisabilityCare will change the existing funding relationships of many service providers, including those
currently providing Psychiatric Disability Rehabilitation Support (or community managed mental health)
Services. This will result in changes to the operation of these services.
54 For example, the 2003-8 National Mental Health Plan did have in advanced draft forms specific, measureable goals and measurement
methodology. These had been developed by the inter-government working groups. These specific details were removed by more senior officials before
the documents were tabled with Health Ministers for agreement.
55 For example: Shine, K 2013. Medieval law jails mentally ill indefinitely. The Australian, 24 June 2013. There are dozens of examples of similar
reports contained in the statutory office reports examined in Chapter 6 of this Report.
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Figure 7: The WHO service organisation pyramid for optimal mix of mental health services
Figure 8: Childs play – A representation of Australiaʼs mental health ʻsystemʼ and funding
percentages and sources56.
56 The representation here is of a child’s set of building blocks. Unlike the WHO Pyramid, there is no logic or relationship between the service
elements. Funding sources and the percentages of funding for each service element are based on AIHW data and are approximations.
Summary Report
46
Many NGO community mental health services receive block funding to do so. Alongside the reform
instigated by the NDIS, for some time there has been a general Australia-wide push away from block
funding towards individualised support packages which place more emphasis on choice and control.
Couple this with new national strategies, new structures such as Medicare Locals and Local Health
Networks, new systems and sector reform means that enormous challenges lie ahead.
Subject to the finalisation of details with DisabilityCare, clients of existing community mental health
services will continue to receive services under their existing arrangements until their area is transitioned
across to DisabilityCare Australia by mid-2016.
The Productivity Commission noted in its report that although the community mental health system shares
similar approaches and philosophies to the NDIS, it is placed within a broader mental health system,
which, “with its clinical orientation, has been slow to recognise these approaches”. The Commission felt
that the extra resources provided through NDIS would strengthen community mental health services.
This is however complex reform intersecting with an already complex and fragmented mental health
system and there will be many challenges, as well as opportunities ahead.
The ʻlifelongʼ approach of the NDIS is very positive, as is the approach of putting people in control of the
care and support they receive, based on their needs. This will create a ʻbottom-upʼ demand for services,
instead of the current, largely ʻtop downʼ, budget driven approach to service provision.
There is however some cause for caution and concern. The predetermined pricing of DisabilityCare
Australia may drive many service providers out of the market. There is also a danger that the quality of
staffing will suffer with price pressures, increasing casualisation, compromising workforce supply,
development and capacity into the future. Some clients will struggle as the services and supports they
are used to change shape and evolve. There will be clients who are functionally more able or better
supported than others to navigate these changes. Those with severe mental health problems may not
fare as well.
The new system already has some well-informed critics:
“The thinking is old fashioned – the architecture of the design is archaic and bureaucratic. Australia
is building the equivalent of a 1970s IBM super mainframe computer in an era of mobile devices
and the Cloud. Modern systems push control and responsibility out towards citizens, allow for
networking, assume capacity and enable open source innovation at every level.”
Simon Duffy Director, Centre for Welfare Reform UK57
It will be important to monitor how the episodic nature of mental illness will sit within a structure largely
built around functional impairments with far less variability and how DisabilityCare interfaces with the
mental health legal system, with clinical services and with programs such as Partners in Recovery.
Partners in Recovery
The Partners in Recovery (PIR) program is a key element of the current Federal Labour Governmentʼs
National Mental Health Reform Plan. With a $550 million dollar investment, it is second only in scale to
the Better Access program introduced by the Howard Government in 2006 and approximately doubles the
investment in the Personal Helpers and Mentors program. Unlike those two programs, PIR is not
designed to deliver services, but coordinate them for a select group of ʻclientsʼ.
Almost all of the investment is in service coordination and ʻsystemʼ development. It aims to reach 24,000
individuals over the three years. It is envisaged that most clients will ʻexitʼ the program and therefore will
not be a PIR client on an ongoing basis. The cost of PIR care or service coordination will be
approximately $23,000 for each client.
57 http://www.centreforwelfarereform.org/library/by-az/fears-for-ndis.html, viewed July 6, 2013.
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On the face of it, it seems consistent with the NDIS ethos of ʻchoice and controlʼ. Whilst both PIR and
NDIS could be considered client-focused initiatives, they are actually working from quite different
directions. PIR is focused on system reform, bringing providers together and creating a more integrated,
collaborative approach to service provision, to the benefit of the client. Whilst we can expect a type of
care coordination function to continue under DisabilityCare Australia, with significant market forces at
play, the possibility is that competition may well drive providers further apart rather than together. System
reform within PIR is top-down; system reform under the NDIS is more bottom-up in nature. Briefings from
the relevant Commonwealth public servants responsible for the two programs revealed little coordination
or alignment58.
Activity-based funding
Under the National Health and Hospital Reforms agreed to by CoAG in 2010 and 2011, health care
services will move to activity-based funding from the 2013–14 financial year.
Prima facie, there is probably no other sector with more to gain from the implementation of activity-based
funding (ABF) than mental health. Stories of funding originally earmarked for mental health being moved
to prop up other areas of the health budget are commonplace. ABF offers new classification and costing
technologies to make transparent what resources are being used and where, severely curtailing the
capacity of hospital administrators to covertly suck funding out of mental health and put it to use
elsewhere.
This same technology offers the prospect of creating a new lingua franca in mental health, national
naming conventions that permit practitioners to establish new benchmarks, to compare like with like and
improve the quality of the care they provide. There are currently no such benchmarking tools available in
mental health in Australia.
While these advantages accruing from ABF are considerable, there are also some immediate problems to
overcome. In the absence of more suitable casemix classifications, governments are likely to use stop-
gap measures such as diagnostic-related groups (DRGs) by which to classify and fund mental health
care. Not only are DRGs not very accurate descriptions for mental health care types, but they are also
not very accurate predictors of patient-by-patient resource use. Until new casemix technology is devised,
the system will be quite inaccurate.
Perhaps more concerning than this however, is the fact interim ABF arrangements will likely perpetuate
the hospital-centric nature of mental health care in Australia, providing new levels of Commonwealth-
funded growth to precisely the wrong areas for the purposes of mental health reform.
The urgent task facing Australia in relation to the application of ABF to mental health is to build an
approach which not only accurately describes the services we want to see flourish in a contemporary
system of care, but one that also has the right financial incentives. Such incentives must properly
prioritise the community over the hospital as the focus of care, including the use of appropriate incentives
and sanctions to help guide decisions about what services to provide and where. Such an approach
would then drive ABF to work consistently with the preceding 20 years of national mental health policies
and plans including, most recently, the Contributing Life Framework issued by the National Mental Health
Commission.
What these policy developments mean for mental health reform
The short answer to this is we donʼt yet know. However it is important to take note again of history and be
aware that the momentum of mental health reform may yet again fall victim to broader health and human
service reforms.
58 Briefings have been attended by authors of this report on several occasions in the past 12 months.
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48
Indeed, here in Australia, ABF models have operated in Victoria for many years and, as was shown in the
Not For Service report in 2005, the access to care and the quality of mental health care (e.g. adequate
length of time for recovery to commence prior to discharge from acute care) is not necessarily advanced
through such funding models.
Equally, the introduction of DisabilityCare Australia will, on the present indications, only provide care for
those 50–60,000 people most severely disabled by mental illnesses. It offers little if anything for the
hundreds of thousands of others with severe mental illness, or the hundreds of thousands of people on
welfare and unemployment payments with moderate levels of mental illness or the 20–30,000 cases each
year of first onset psychosis. Indeed as is becoming evident in the NDIS trial sites, it may reduce access
to services for those not deemed eligible for DisabilityCare.
5.2 Scaling innovation and evidence-based practice
Innovation and the ability to apply evidence routinely are often cited as key factors in any organisationʼs
success59. McDonalds, the global fast food giant, has a stunningly simply but seemingly effective
business strategy: “think big… start small… scale fast”. It means to continue to be successful, the
organisation must foster and support innovation and creativity, prove it works (test it, stress it, try to break
it) and then move quickly to market ahead of competitors – think big, be brave, be quick.
Delivering effective mental health care is obviously more complex than selling food, but the McDonaldʼs
strategy principles could be applied to overcoming some of the problems evident in mental health care in
Australia.
In every area of health care practice, there is a lag time between novel approaches becoming the new
standard of appropriate or guideline based care and then a further lag to when they become the routine
practice of those delivering care. In mental health, that lag time is too long. The evidence presented in
this Report raises many questions regarding the quality of mental health care. A preliminary list of mental
health care practices and models where there is robust evidence to support the widespread application
and availability in Australia. It is not a definitive list, but illustrative of the problem. We need to have the
commitment and strategy to urgently scale these across the nation.
5.3 The Manifesto for Change
The next section of this Report sets out a Manifesto for Change. There are five strategic issues
addressed in the Manifesto: Governance; Quality of Care; Workforce; Research and Evaluation; and
Funding. There is an urgent requirement for a ʻroot and branchʼ review of the governance of mental
health in Australia, bolstered by new attention to accountability, research and workforce development.
Together with a commitment to a fair share of funding allocation, these are the building blocks of real and
sustainable mental health reform.
59 Go to Harvard Business School Working Knowledge – topics Innovation: http://hbswk.hbs.edu/topics/innovation.html
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6. Obsessive Hope Disorder and a Manifesto for Change
The history of Australian mental health reform over the past three decades is one of world class policies
and strategies let down by inadequate planning, poor implementation and our complex system of
government. The results have been disappointing, wasteful of scarce resources and all too often,
devastating for the millions of Australians affected by mental illness.
Despite this, many consumers, carers and people working in mental health remain positive. They are
afflicted with a condition known as ʻobsessive hope disorderʼ, a condition which permits them to
understand mistakes of the past and plan a better future for mental health. Obsessive hope disorder
(OHD) is characterised by a willingness to keep hoping, keep dreaming.
We strongly believe that OHD can be cured, that mental health reform is both practically possible and
enjoys overwhelming community support. From the evidence and the analysis presented in this Report,
the key to curing OHD is immediate attention to five urgent elements of reform: governance; quality of
care; our workforce; research and evaluation; and funding.
Area 1 – Governance
The recent involvement of the Council of Australian Governments in mental health since 2006 has been
most welcome. However, a legacy of recent reforms has been to exacerbate role confusion between the
states and territories and the Federal Government. The key to a better future for mental health in
Australia must be to end this confusion and put in place new, clarified governance arrangements for
mental health. We need to get better organised to end waste and duplication and maximise the
investment return. This should be done in several interrelated steps:
1. A study to establish cost of mental illness. So as to definitively understand both the scale of the
problem and the investment required, the Productivity Commission should conduct an inquiry to
develop a complete picture of the cost of mental illness and suicide to the Australian community.
2. A national review of roles. The second task for the Productivity Commission is a formal review of
the current roles and responsibilities for mental health across Australia. Current role confusion is both
wasteful and unsustainable. It must also answer questions regarding the service mix and scale to be
available for a given population as well as issues of national quality standards. The Productivity
Commission would be charged with providing clear recommendations about how to drive
improvements.
3. National Mental Health Commission as a statutory authority. The next step would be to enhance
the role of the National Mental Health Commission. To be to be effective it must become a more
genuinely independent body, with statutory powers of inquiry and reporting functions to the Australian
Parliament. A revamped Commission must have both the statutory powers and resources necessary
to develop, monitor and independently report on national mental health policy, programs and
outcomes in Australia.
4. A national audit of mental health programs. An important first task for a revamped National
Commission is a nationwide audit of mental health services. The approach to service development
over past decades means that the nature and quality of care varies wildly depending on where you
live. A national audit would for the first time map the type and quantity of services available across
Australia, as well as document any evidence regarding the effectiveness of these services.
5.
The National Mental Health Report Card. A further key role for the Commission must be the regular
public reporting of our progress towards reform. The National Mental Health Report Card must
become the focus of our efforts to provide consumers, carers, service providers, policy-makers,
researchers and funders with clear advice about whether what we are doing is really improving the
lives of people with a mental illness. The Report Card must include data on life expectancy.
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6. Independent program evaluations. Program evaluations must be conducted independently of the
departments and agencies responsible for the development of policy and the administration of
programs. This responsibility, and the funding, should be moved to an appropriate independent body
to manage, e.g. the National Mental Health Commission, the Australian National Audit.
7. Model legislation and legal processes. Harmonisation of legislation in mental health care was a
goal under the first National Mental Health Plan. Regrettably, we still have significant variations in
mental health legislation in Australia. The National Mental Health Commission should work with
states and territories to establish an agreed best practice approach for the justice system.
8. Discrimination law. Housing, employment and social participation opportunities are frequently
denied to people with mental illness. On the basis of the evidence in this report, the Australian Law
Reform Commission should be asked to examine the provisions of Australian law and international
experience and bring recommendations before the next Parliament for consideration.
9. Inquiry recommendations. Recommendations formulated by statutory authorities and government
reviews frequently are not addressed or implemented by the respective government departments or
agencies. This is a broader whole-of-government governance issue and not unique to mental health
services. To address this, recommendations arising from reviews and the resultant actions need to
be included in annual reports of government agencies.
Area 2 – Quality of care
The quality of mental health care across Australia remains highly dependent on where you live, your
capacity to pay for services and your determination and persistence (or that of your loved ones) to get you
to care. Astonishingly, we still see hundreds of Australians held indefinitely in stand-alone psychiatric
facilities twenty years after all Australian governments agreed to close these relicts of the 19th Century.
This is indefensible and a continuing violation of human rights.
The lack of a national service framework, agreed models of quality care, particularly community based
mental health care, the lack of care guidelines60 and defined pathways to and from care, means people
needing mental health care enter a bizarre lottery. This is possibly a key factor in the reluctance of so
many Australians, whilst increasingly aware of mental illness, to seek help.
Real improvements in quality of care rely on the following elements:
10. A national service framework. There is no clear and shared understanding as to what community
mental health care looks like – the architecture never drawn. This must change. The spectrum of
services, the standards of care and the pathways to and from care can be articulated through a
National Service Framework agreed to by all governments and the sector. The National Service
Framework must clearly articulate and define the mix of services: prevention, early intervention,
primary care, specialist care, community based care, acute and sub-acute hospital based services.
Leadership for the development of the Framework should be vested in the revamped National Mental
Health Commission and co-chaired with one of the new state mental health Commissions.
11. National models of care. A clear, progressive National Model of Community Mental Health Care
informed by international experience and evidence is the basis for higher levels of consistency in the
provision of services. The deployment of a national model of care and the development of pathways
to/from care for specific mental health problems supported by national training will improve the quality
of care.
60 In Australia there are just four Clinical Guidelines relating to mental health conditions issued by the NHMRC. They are all medical in emphasis. In
the UK, there are over 30 current and approved care guidelines issued by the equivalent body.
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12. Investment in e-therapy and online services. In the past few years, governments have begun to
invest in universally accessible telephone helplines and online service platforms available 24/7. The
deficiencies in current services, the workforce constraints, the mal-distribution of Medicare-funded
services and Australiaʼs dispersed population make investment in 24/7 telephone and online services
a no-brainer. These services can be a pathway into care for some and improve care continuity.
13. Employment policy. Another consistent theme in the evidence gathered for this report is the failure
of employment policy to address the needs of those with mental illness. Employment is a proven
component of recovery from a mental illness for the vast majority of people. Employment policy must
be framed on the basis of evidence. This is a very simple proposal. The savings to the government
budgets, the improvement in productivity for our nation, the improved quality of life and prospects for
recovery for these Australians will be the payoff. Itʼs that simple and the need is urgent.
Area 3 – Our workforce
Mental health needs to be a place people want to work. Thirty years ago David Richmond made
numerous recommendations relating to the mental health workforce and its needs to successfully
transition to community based care. In the years since, the evidence in this report shows many of his
recommendations have been repeated and further developed by other reviewers. Over and over again,
one reads of the urgent need to act on workforce reform and development.
Despite the unequivocal message to act urgently and assertively on workforce, the best we have seen is
an investment of $287 million over five years (or just $57 million per annum) under the COAG National
Action Plan on Mental Health 2006–11. This is too little and it is getting close to being too late. The
following key steps must be undertaken:
14. A National Mental Health Workforce Institute. Australia needs a National Mental Health Workforce
Institute specifically established to nurture the workforce of the future and ensure that mental health is
a sector where talented people want to work. The systems approach and ʻstarter kitʼ presented in this
report provide a basis and focus for the Institute.
15. A national workforce plan. There are already unsustainable pressures on our mental health
workforce. There is no national plan to arrest this situation. The Institute would be charged with
developing this plan to address not only the size, make up and competencies needed for a
contemporary mental health workforce, but also ways of working, the desired culture and leadership.
16. New roles. A core focus for the Institute would be designing new roles for peer workers and
strengthening the definition of community mental health workers. Greater involvement of peer
workers in the delivery of community and hospital-based mental health care is probably key to making
our future workforce sustainable. The same is true of community mental health workers. New e-
health services require e-health workers to be trained. We also need to ensure enough staff to make
the most of new investments in youth mental health, such as the early psychosis (EPPIC) services.
Area 4 – Research and evaluation
Despite the prevalence of mental illness and the burdens of disease (13%) and disability61 (24%) mental
health research remains stuck at less than 8% of total national research funding. This is puzzling at a
time when we are looking as a nation for ways to lift our declining productivity. Maybe itʼs time for a
mental health research-led recovery, using the following approach:
61 Begg S Vos T Barker B Stevenson C Stanley L Lopez A 2007. The burden of disease and injury in Australia 2003. PHE 82. Canberra: AIHW.
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17. A National Institute for Translational Research in Mental Health. Funding for mental health
research has unfairly failed to reflect the burden of disease. Where funds have been provided
(largely by the NHMRC) they have focused on the laboratory rather than translational or service-
focused research. A new National Institute is a priority initiative, to enable greater focus around
mental health research, promote collaboration between existing researchers and ensure proper
attention on translational research.
18. Prioritised funding for research. What is clear is that in Australia, medical research is funded on
the basis of demand and not epidemiology or national priority. Putting it bluntly, those with the
greatest capacity, get the greatest allocation of public research funds. The new National Mental
Health Research Institute would require funds of $100m to be drawn from the existing NHMRC
budget (approximately 12% of current funding).
Area 5 – Funding
Many of the ideas put forward in this Manifesto cost little. However, and as recommended by successive
inquiries and reports, real reform of mental health will require more resources, as well as more intelligent
use of resources. The following steps are necessary.
19. A fair allocation of funds. While the financial constraints facing Australia are acknowledged, and
even with recent increases in spending on mental health, the rate of overall increase to the annual
health budget means mental healthʼs share is actually declining not increasing. A better future for
mental health in Australia rests on a fair allocation of funds. Mental healthʼs share of the total health
budget should be 12% by 2020.
20. Examine funding models. At the moment a key driver in mental health is not what works but who
pays, an unhelpful legacy of the confused governance arrangements between the states and the
Federal government. Another key task to be undertaken by the Productivity Commission therefore
must be to examine funding models and options for mental health in Australia, including consideration
of alternatives internationally.
21. Funding directed to evidence-based services. New funding must be directed to the ʻbest buysʼ in
terms of evidence. Australia still spends more than half a billion dollars a year on stand-alone
psychiatric facilities and some states are still spending over 50% of their entire mental health budget
on hospital-based acute services – this is an inefficient policy choice. The results of the audits and
reviews set out earlier and the National Service Framework must drive investment in mental health
over the next decade.
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Conclusion
Obsessive hope disorder (OHD) is a serious matter. Given what we know, probably the entire Australian
population is afflicted, knowing that mental health care in Australia is not good enough and really wanting
things to improve. Some people have been affected by OHD for thirty years; more recently as their
understanding of mental health has developed. It is long past the time to deliver on the intentions of
David Richmondʼs 1983 report and the promise of community-based care for people with mental illness.
It is long past the time to end stigma against people with mental illness. It is time to respond with what is
required to cure obsessive hope disorder.
This Manifesto has described key elements of the remedy, and the essential steps to be taken in the
effective treatment of OHD, to end the cycle of neglect in mental health care.
There is an urgent requirement for a ʻroot and branchʼ review of the governance of mental health in
Australia, bolstered by new attention to accountability, research and workforce development. Together
with a commitment to a fair share of funding allocation, these are the building blocks of real and
sustainable mental health reform.
This Manifesto will help turn Australiaʼs inextinguishable hopes and dreams for a better future for mental
health into a reality. Itʼs about time!
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Appendix A – Key issues and recommendations from evaluations of national MH plans
Notes: 1. There has not been an evaluation commissioned or undertaken of the Fourth National MH Plan (2009–2014).
2. The statements here are based on the conclusions reported by the authors of the three Evaluation Reports. Abbreviations have been used in places.
Review of the NMHS 1992–1997 Evaluation of the 2nd NMHP 1998–2003 Summative Evaluation of 3rd NMHP 2003–2008
Service delivery, standards, quality, outcomes, innovation, funding, resourcing and mental health needs
Key findings:
1. Service improvements – uneven, nationally and
locally.
2. Many areas yet to see tangible benefit from reforms –
structural reform agenda is incomplete.
3. Slow to act on poor service quality and client
outcomes.
4. Exclusion of both private psychiatric hospitals and
Psychiatrists was poor policy and now chronic problems.
5. Lack of development of GP-specialist services.
6. Widespread application of the term ʻserious mental
illnessʼ in restricting access to services.
7. Lack of service planning (for population needs).
8. Funding policy is the vital force in driving change.
9. A role yet to be developed at the national level is the
provision of training and support to agencies
undertaking service innovations.
Recommendations:
1. Focus on service standards, quality and outcomes.
2. Much more work to fully accept and implementation of
outcome measures and service standards.
3. Implement the recommendations from McKay review.
4. Need to move from isolated pilots to a structured
program of change for GP-specialist MH services.
5. Extent of community need must be determined so
local priorities and service gaps can be properly
identified.
Key findings:
1. Continuing problems with access to care (timely and
appropriate) within and beyond the specialist MH sector.
2. Access to acute care is esp. problematic and the
current practice whereby consumers often cannot
access acute care until they have reached a crisis must
be redressed.
3. Barriers to accessing long-term care in the community
and ongoing support services.
4. Lack of population planning.
5. There must be a strong commitment to ensuring
effective innovations become part of mainstream MH
care by being fully integrated and resourced within the
MH care system.
6. Funding formula and accountability mechanisms can
ensure money is effectively devoted to mental health.
7. An adequate level of resourcing, providing a balance
across the entire spectrum of MH interventions, is
needed to meet Australiaʼs growing MH needs.
Recommendations:
1. Address access to care and access to support
programs in community.
2. Care should be responsive to developmental course
of MH problems and illnesses. Need specific service
models for different groups.
3. Need to make early intervention models (e.g. EPPIC)
more widely available, and develop models for other
disorders.
Key findings:
1. Major problems with service complexity and funding
complexity.
2. Current complexity of service systems may see
adverse impacts on people with MI.
Recommendations:
1. A whole of government approach is required to deliver
the cross-sector changes.
2. The need for a clear and coordinated partnership
across and within governments.
3. The opportunity to build upon the whole of
government opportunities provided by the success of the
COAG Action Plan.
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6. Tools need to be developed that fit the requirements
of MH services, which emphasise continuity of care
across hospital and community boundaries.
4. Evaluation of care models warranted.
5. Need to develop coordinated models of care.
6. Funding models must be developed to ensure that
innovative ideas and pilot programs that are evaluated
as effective are sustained.
7. MH must be afforded greater priority, commensurate
with its health impact and the high level of unmet need.
Consumers and carers
Key findings:
1. Consumers and carers have limited influence on local
services, even when it concerns personal treatment.
Recommendations:
1. A national group of consumers and carers be
maintained and extended.
2. Guidelines and assistance to local agencies, public
and private, need to be established to accelerate the
empowerment of consumers and carers.
Key findings:
1. Services lack responsiveness to consumer and carer
needs.
2. Carers too often not involved in treatment planning
3. Community support services are not funded to do
what is required.
4. Participation remains largely tokenism.
5. There continues to be evidence of consumer neglect,
as well as outright human rights abuses. This will entail
monitoring of inpatient care and follow up on discharge,
through the full implementation of consumer outcomes.
Recommendations:
1. The enhanced role of carers and community support
services and organisations must be sustained and
prioritised.
2. Must be better access to respite services.
3. Full and meaningful participation for consumers and
carers at all levels of planning and service delivery.
4. Full implementation of consumer rights and
outcomes.
Key findings:
1. Consumer and carer participation has seen some
progress.
2. Governments rely on one mechanism to gain a
consumer perspective.
3. A lack of recovery focus in services.
Recommendations:
1. Need to develop a range of consumer perspectives.
2. Need for clear and transparent reimbursement
structures for consumer and carer participation.
3. An overall system focus on recovery and social
inclusion is required.
4. Focus on the regular use of Consumer Experience of
Care surveys to track trends and identify key action
areas.
Workforce
Key findings:
1. No action taken in critical areas, e.g. workforce
training.
2. Little done at national level to address workforce
implications of changes in service delivery (i.e. from
institutional to community care).
Key findings:
1. Little progress on developing the MH workforce.
2. The distribution and composition of MH workforce is
not aligned to population needs.
Key findings:
1. The challenges across the entire MH workforce pose
the greatest current challenge to the sustainability of a
viable MH system of care.
2. “A sufficient workforce is a fundamental precondition
for successful implementation (of Strategy)”.
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3. Confusion about the values, attitudes and skills
required to work in mental health. Little done on defining
core competencies.
4. Tokenistic reference to consumer and carer
participation.
Recommendations:
1. The need for a coherent national workforce plan.
2. Define the core competencies needed by MH
professionals.
3. Implement the recommendations from McKay and
other workforce reviews.
4. These then should be used in negotiations with the
tertiary education sector and form the basis for
professional development initiatives within the industry.
Recommendations:
1. Innovative solutions to address the inequities of
service access must be found.
2. Training and development must be to change
attitudes, orientation, skills and historical practices of
MH workforce to promote recovery and social and
emotional wellbeing.
3. A lack of coherent, national workforce plans.
4. Lack of service mapping impacting on staffing plans.
5. Need to identify best practice to recruit/train/
reward/retain staff.
6. The “scale, urgency and trends in the issues mean …
that a serious healthcare staffing challenge” confronts
Australia and “should not be underestimated”.
Recommendations:
1. A clear forward coherent and robust plan is required;
specifies the numbers of staff needed with defined skills
and competences, up to 10 years ahead and across all
sectors providing services for people with MI.
Rehabilitation and recovery, including housing and employment
Key findings:
1. An imbalanced system of care with too much
emphasis on the treatment of acute symptoms and too
little emphasis on personal recovery, integration, and
rehabilitation.
2. A lack of services for people with long-term illness or
severe episodic illness.
3. Role of NGO sector is valued highly by consumers.
Recommendations:
1. Effective treatment of symptoms needs to be
accompanied by approaches that emphasise personal
recovery, integration, and rehabilitation.
2. A better balance of approaches is required to improve
long-term consumer outcomes.
3. The need to achieve a balance of illness and
rehabilitation approaches requires coordination of
services rather than segmentation.
Key findings:
1. Persistent inequities regarding access to
accommodation, employment, education and training,
income support, disability services, and domiciliary care.
2. Lack of coordinated care and recovery approach
within services.
3. Continuing stigmatising attitudes and discriminatory
practices in a range of services.
Recommendations:
1. A fully integrated system of MH care requires
expanding service frameworks beyond the health
system, to incorporate the disability, accommodation
and wider welfare systems.
2. Equitable access to and better coordination of support
services must be achieved for accommodation,
disability, employment and health services.
3. The need for a whole-of-government approach.
4. MH services must begin to operate within a
framework that supports the empowerment of
consumers and personal capacity building.
Key findings:
1. Lack of employment opportunities.
2. A critical shortage of housing (both capacity and
range).
3. Continuing disconnections across government.
Recommendations:
1. Renewed whole-of-government focus needed on
workforce entry and retention, incl. the full application of
the Disability Discrimination Act to people with MI.
2. Extend consumer, consultant and peer support
worker schemes.
3. Information and evidence of best practice
accommodation models, with action plans,