Reform: How to get it done, and how to make it stick

If reform is at the heart of what we do as mental health stakeholders, then the key question for mental health reform in Australia is not what needs to be done, but how to get it done, and how to make it stick.

We have a long history of inquiries, reports, reviews and recommendations going back decades, many of which repeat the same issues over and over, but at the end of the day, genuine, long-lasting change has eluded us all.

There have been many notable inquiries over the years, by eminent and well-qualified people who recognised the need for significant reform.

However, the commitment to reform has all too often waned once the glare of public attention and media-driven discomfort evaporates. The hopes and expectations of people with lived experience too often also evaporate along with the headlines, as each inquiry or report fades into history.

There have been numerous comprehensive reports and recommendations that—if only they had been implemented at the time in full, with appropriate funding, organisation, innovation and motivation—we would have a different system to the one we are still grappling with today.

The Royal Commission

A regular and prominent feature of the mental health reform landscape is the Royal Commission, one of which, as you know is currently occurring in Victoria.

Royal Commissions have been described as the “institution of last resort” for governments that have exhausted other options for handling highly sensitive or contentious issues[1].

As so often has been said, they are the marker of a system in crisis.

On the one hand a Royal Commission can bring the cleansing light of inquisitorial review, with all the powers and resources of a royal commission.

They can effectively highlight the deficiencies in the system; they can consider and analyse a wide range of viewpoints, data and material[2]; they can expose the often-terrible experiences of people with lived experience; and they can make extensive recommendations for change.

On the other hand, I would argue that our job as custodians of the mental health system (and by this I include governments of all levels and persuasions), is to avoid crisis.

Royal Commissions are also expensive and can themselves lack transparency or review of their processes and findings[3]. However, I think the most significant flaw of the royal commission model for reform is the high risk of failure, not in the inquiry itself, but in follow-through and implementation once the urgency of crisis dissipates.

This raises the question of whether royal commissions are in fact, the best mechanism for real and lasting reform.

Despite this, the fact remains we have repeatedly failed to learn the lessons of the past, whether via royal commission or other mechanisms of review.

In a recent article, Sebastian Rosenberg and Ian Hickie counted 32 inquiries into the sector from 2006 to 2012[4]. This includes a range of inquiries “conducted by health departments, coroners, auditor-generals, parliamentary committees and non-government organisations”[5].

So, let’s look at the history of mental health reform over the past few decades in Australia in the context of all these inquiries and reviews.

The Richmond report

Thirty-six years ago, in 1983, the landmark Richmond Inquiry in NSW made recommendations in the context of ongoing de-institutionalisation in that state, the first of which was:

That services be delivered primarily on the basis of a system of integrated community-based networks, backed up by specialist hospital or other services as required.[6]

Richmond said the two prime operational objectives were to fund and/or provide services which maintain clients in their normal community environment; and to progressively reduce stand-alone psychiatric hospitals in favour of a decentralised service model[7].

His proposals included additional community-based crisis teams; staffing to provide adequate follow up for people in the community and the provision of linked networks of accommodation and housing.

The report also highlighted the role of community mental health nursing and better coordination and integration between GPs and public mental health services.

Richmond also urged that mental health funding be given priority consideration in health budgets, and for funds to be ring-fenced for new services.

Richmond outlined the means to fund these changes through savings gained by progressively closing existing stand-alone hospitals and utilising these funds to establish a range of community mental health services.

Perhaps the final word on this significant reform agenda should go to Richmond himself, who said in recent years:

Despite broad adoption of the Richmond philosophy, and some early implementation momentum, reform and progress have been slow and very much “stop/start” in nature. More than 30 years later, despite numerous “pockets” of excellent practice, mental health is still underfunded and continues to be locked into hospital care… (and)… issues such as housing and accommodation, employment, social inclusion and avoidance of stigma are still key challenges.[8]

Much of the blueprint for what we consider essential reform of the mental health system was provided by Richmond.

Yet today, many of the same issues still exist, with the “majority of state-funded mental health services still provided as either hospital inpatient, outpatient or emergency services”[9].

Funding has simply shifted from stand-alone psychiatric hospital-based care to acute psychiatric care in general hospitals.[10]

The Burdekin report

The Richmond report was followed a decade later, by Brian Burdekin’s landmark National Inquiry into the Human Rights of People with Mental Illness.

Burdekin specifically took a national approach – for the first time examining the laws and provisions in each state, but also examining the “apparent” defects of de-institutionalisation and taking a rights-based approach rather than a service-based perspective[11].

In particular, Burdekin noted:

It is not acceptable to have lower standards for mental health care, in terms of either standards or resources, than in the rest of the health system.[12]

He emphasised the concept of ‘least restrictive’ practice in a safe, therapeutic environment, as well as the right to be treated and cared for as far as possible in the community.

He reiterated Richmond’s support for community mental health, saying “treatment in the community must have adequate resources to provide effective care”[13].

His approach was ground-breaking because he also took a holistic view of mental health care that incorporated employment, education and training, and housing and homelessness.

Interestingly, Burdekin also hinted at a culture of responsibility tennis between the states and Commonwealth that exists to this day.

The Burdekin inquiry and the National Mental Health Strategy accelerated the pace of de-institutionalisation, and brought about significant change and achievement, particularly in the mix of mental services.  

This decade also brought badly needed additional investment — with government spending on mental health growing to $3.1 billion or by 65 per cent between 1993 and 2002[14]. However, this jump is commensurate with the growth in health spending overall, rather than a specific strategy to expand mental health service delivery, and was patchy — with huge variances in per capita spending across the states and territories to this very day.

Professor Harvey Whiteford noted at the time that: a “legacy of 30 years of de-institutionalisation… saw the number of psychiatric beds decrease from 30,000 to 8,000, with limited development of community services, and a doubling of Australia’s population”[15].

The gains were short lived, as significant challenges were again evident at the start of the new millenium.

Not for service report

In the first years of the 21^st century, the cracks began to reappear, with mental health once again battling for funding and attention, and the established cycle of crisis/review continued.

In 2005, in the boiler room of adverse publicity and mounting professional concern about the adequacy of mental health care, several national inquiries were born[16].

The need to expand the quality, as well of the quantity of mental health services was underlined by the National Mental Health Strategy.

In 2005 the report Not for Service: Experiences of Injustice and Despair in Mental Health Care in Australia shone a light on “stories of systemic failure, neglect, the lack of accountability and the continued neglect of workforce issues in all parts of Australia”[17].

Keith Wilson, the Chair of the Mental Health Council of Australia stated the report was met with “a level of defensiveness and a rejection of the findings”[18] by a number of jurisdictions, noting these same governments had not “implemented basic and routine needs assessments nor regular and system-wide evaluations”[19].

The report called on all Australian governments to commit to a process of genuine and well-resourced reform. It pointed to “fundamental service failures” and called for “Independent and genuine scrutiny of progress” as an essential ingredient for ongoing reform.

The report’s authors concluded: “we should have in place government-supported but independently conducted systematic reviews of access to care, experiences of care and human rights”.

National Mental Health strategies

At this point I’d like to talk briefly about the National Mental Health Strategy. As you know, the first National Mental Health policy was introduced in 1993, followed by a series of five-year plans, each articulating priority areas for investment and reform.

These plans were constructed around the concept of ‘progressive’ reform. That is, each plan in theory builds on the achievements of the last, moving on to the next focus area without necessarily or objectively measuring whether earlier objectives or outcomes have been substantially realised.

Without effective mechanisms of review, focus and attention has shifted from one thing to another, or been spread “a mile wide and an inch thin”, to quote Professor Patrick McGorry.

The vital importance of national and state-based strategies is undisputed, however rigorous, system-wide, empirical evaluation is critical for reform, to enable reform to be guided by the evidence, rather than a piecemeal or patchwork approach.

2006 National Action Plan on Mental Health and $5.5 billion additional funding

Another milestone was the 2006 Australian Senate inquiry, ironically titled ‘From Crisis to Community’, which recommended the creation 400 community mental health centres nation-wide. This too ‘went the way’ of many soundly-based recommendations.

However, 2006 provided a tipping point as COAG agreed on a five-year National Action Plan on Mental Health that articulated roles and responsibility for action as well as individual implementation plans for the Commonwealth, states and territories.

In this same period, COAG added more than $5.5 billion to mental health spending — much of it towards the Medicare funded Better Access initiative, which broadened access to secondary service providers for those with mild to moderate mental ill-health[20].

The 2011-12 Federal Budget added $2.2 billion in new funding, including $550 million for Partners in Recovery and $270 million for PHAMS, which are now being cashed out into the NDIS.

In 1992-93, mental health accounted for 7.25 per cent of the total health budget[21]. This dipped to 4.9 per cent in 2004-05 and by 2014-15 it was noted that much of the earlier spending zeal had stagnated, with mental health observed to “remain chronically underfunded”[22].

In 2015-16 mental health spending had crept back up to 7.67 per cent of the health budget, or in other words, mental health had achieved the same level of spending as 1992-93, while accounting for 12 percent of total burden of disease[23].

As one leading researcher noted: “After… decades of reform and change of the Australian mental health system, and an injection of $5.5 billion, significant gaps in care remain, with little available evidence about improvements in outcomes and access to care”.[24]

In the decade to 2014-15, per capita funding grew in real terms by approximately 30 per cent, most of it attributable to the period between 2006 and 2010[25].

Achievements of note include significant investment in youth mental health, but gaps still remain for those in the ‘missing middle’.

However, since 2014-15 growth has again been turbulent, if not sluggish, with slowing expenditure by the states and per capita funding for clinical community mental health care actually falling, despite population growth[26].

This means demand continues to be “transferred to a hospital-centric system already too low in beds to cope, and all balance has been lost”[27].

Despite increased funding over the last few decades the prevalence of mental illness has barely changed. This begs the question — are we investing in the right areas[28]?

National Review of Mental Health Programmes and Services

By 2014, the Commonwealth tasked the National Mental Health Commission with conducting a national review of mental health programmes and services to assess the efficiency and effectiveness of supporting people with mental ill-health.

The Commission was set the unenviable task of “baking a ‘magic pudding’” – that is, of driving reform without the injection of new resources: a strategy doomed at the outset because it didn’t address the fundamental issue of ongoing systemic and chronic underfunding of mental health services across the country.

To its credit, the Commission undertook a comprehensive and robust evidence-based approach to reallocate existing resources upstream into early intervention and prevention.

Their review resulted in 25 recommendations, the most critical being a suggestion that $1 billion in projected growth funding over the subsequent 5 years be diverted from hospital-based mental health services to community-based services. Without any due consideration this option was immediately dismissed by the Minister of the day.

This initiative, if implemented would have substantially increased and rebalanced investment from expensive tertiary services, often delivered too late, into more effective, holistic and cost-effective community-based services.

The review also pointed to a “poorly planned and badly integrated system” despite an almost $10 billion annual expenditure on mental health services.

Perhaps it is with irony that the report’s authors noted:

… it is clear the mental health system has fundamental structural shortcomings. This same conclusion has been reached by numerous other independent and governmental reviews.[29]

Perhaps the root of the problem is that governments have for too long cherry-picked review and inquiry recommendations, rather than making a substantive long-term commitment to mental health reform.

The picture today

So where does that leave us today? 

Mental health funding appears to seesaw up and down without any coherent strategy to reallocate or lift recurrent spending to match the level of need. We must address this.

The recent KPMG report Investing to save, provided a coherent strategy for upfront mental health investment, as well as clear economic and social benefits from doing so. The recommended investments were costed at $4.4 billion, but were estimated to generate between $8.2 and $12.7 billion[30].

There has also been a suggestion that perhaps the Better Access program, which is estimated to cost $15 million a week[31] may be a means to better target support to the ‘missing middle’.

There are some green shoots nationally, and also here in Queensland. Against tight fiscal settings, we have focused on ‘best buys’ and managed to secure additional funding for community mental health, suicide prevention and alcohol and other drugs services in recent years, including in this year’s budget. 

However, without continued investment and innovation, the inevitable cycle of crisis/review may continue — the Victorian Royal Commission being the latest in this long-running series.

But, rather than wait for the next crisis, we have a real opportunity to learn from the lessons of the past.

There are high hopes for the current National Productivity Commission inquiry into the Social and Economic Benefits of Improving Mental Health within and beyond the healthcare system.

Similarly, the National Mental Health Commission’s 2030 Vision for Mental Health and Suicide Prevention will further extend the national conversation.

The current standing mental health Commissions are also uniquely positioned to contribute to the reform effort and oversee, monitor, review and report on implementation progress.

While independent, we work closely with respective State and Commonwealth Governments on strategy, system review, accountability and innovation.

The concept of transparency should not solely exist in the cold inquisitorial light of a Royal Commission. It must be a standing feature of a healthy system and overseen by standing commissions where ever possible.

Rigorous system review is especially critical for us to evaluate where the system is at, keep a wary eye on existing and emerging trends and issues, examine the data, and measure system effectiveness.

For example, in Queensland and in other jurisdictions, it would be beneficial if mental health funding could be quarantined and be able to be more clearly followed from Treasury to the Department of Health, to Hospital and Health Services, and to front line mental health services in HHSs.

We must keep in mind that a review asks a different question to a strategy. A review asks where are we at now? A strategy asks where are we going?

Or as Professor Alan Fels said, we need to:

“tell the truth about mental health services in Australia — the good, the bad, the gaps and the shortcomings… to observe, listen and then – with fierce independence – report and advise on what needs to happen based on the lived experience of consumers, carers, families and the community.”[32]

My conclusion is this — a number of these inquiries and reviews were undoubtedly necessary to shine a light on the challenges in the system and to reinvigorate ongoing reform.

In most instances, the failings have been related to implementation of suggested recommendations and not necessarily of the reports produced themselves.

Before we consider more inquiries, I would suggest that our first step be that we review:

• What has been implemented as a result of previous inquiries and review
• What has not been implemented, and
• More importantly, have people’s lives changed for the better — or worse — as a result.

Standing Commissions such as the Queensland Mental Health Commission should have clear legislative mandate to undertake such reviews.

Additionally, commissions should also monitor, review and report on implementation of other reviews and inquiries, and — most importantly — the impact they are having on the lives of people with lived experience.

Periodic inquiries and reviews are necessary because people’s expectations of the system and their needs change over time.

At present, we are living in unprecedently changing times.

The wold is a very different place to 1983 when Richmond first undertook his review.

In many respects, the issues have not changed, however, we have — as both individuals and a community.