Mental health reform at the crossroads

Mental health reform at the crossroads

Frank Quinlan
27 April 2016

This webinar examined the current “wheels in motion” of Commonwealth reform processes, and highlighted the implications for other service sectors.

Mental Health Reform at the Crossroads

Audio transcript: Mental health reform at the crossroads

Audio transcript (edited)


Mental Health Australia, as the introduction implied, is a big body in the mental health space. And so I think we're well placed on having a vision as we do across a range of areas to consider the subject of today's webinar, which is mental health reform at the crossroads. So, I intend to just step through a range of thoughts, really, that are largely reflections on the reforms that are underway at the moment, and then to try and get to some of the very particular implications that I think that that has for us in today's ever moving and fast changing environment. So, I'll talk a little bit about the various, as I describe them, policy wheels that are in motion currently. Because I think there are many, I think it's dangerous to talk about unprecedented levels of reform.

But I do think that that's a fair tag in the current environment because there are so many things happening in the mental health space concurrently, that the impacts, I think, are very difficult to predict in lots of areas. I want to talk a little bit about what that means for the changed funding environment and, in particular, what that means for not-for-profit organisations. But it's not just NGOs who are going to be affected by this. There are a range of clinical practices and so forth that are also going to need to adjust. I think it's often hard to, in the midst of all that reform process, sometimes just to step back as we are today and to consider those issues a little more at arm's length. I also want to talk about the changed philosophical approach. Philosophical approach wasn't quite the right language to use there, but I'll come to that later on.

No, but I do think we're in the midst of another revolution as it were in terms of service provision and, in particular, the approach to what we often call the client's sense of practice or the patient's sense of practice. And as I said, I want to just discuss the implications of all of this for NGOs that are working in the field and for people who are working in related sectors. And they're reflective comments rather than definitive comments because I think so many of us are uncertain about exactly where some of these measures are going to land.

Before I do that though, I do wanna talk a little bit just about change because, as I've said, there's an enormous amount of change occurring as we speak but we're not unused to the idea of change. I've got a couple of slides here that usually get a laugh from the audiences that I present them to. So, I'm imagining, hopefully, a little virtual chuckle around the country at the moment. This picture is simply an ad taken from one of the major papers at the time for one of the early model computers, which I hope you can see is intended to be future-proof, thinking ahead for the 80s. A computer that had 64 kb, not mb, 64 kb of RAM at standard with an option to expand that to 256 kb.

And my purpose for showing this slide is that it's really actually not that very long ago. My kids would probably argue with me about that. But I think in terms of the sort of scale of change, to be talking occasionally and lifting our heads up to think, "What is that sort of 10 year and 20 year horizon for the change that we're involved in? And what might that mean things look like?" The other thing that I think is striking about this picture is that the company, the First Order Mover, no longer exists. So, when they thought they were thinking ahead, when they thought they had a great product at the bargain basement price of $6,000, US, I might add, nonetheless that company's passed by the way. And I think that's the other thing that we need to recall in relation to change, is that new things come but old things also pass away.

As my introduction said, I worked at the AMA for some time and, working with the doctors there, this was one of the stories that was often told about the way in which doctors promoted smoking at various stages during history. The reason for putting this slide in here is to say that how evidence changes and can change quite dramatically. And I think that we need to try and hold in our minds the idea that the things that we take for granted today may well be completely turned on their head not very too long into the future. A careful sort of analysis of our preconceptions about the things that we think are really the sorts of things that we must preserve during a time of change warrant some very careful reflection. This is not least true in the mental health space where we've seen quite radical reforms. Again, I'm hoping I'm hearing a virtual chuckle around the country.

I often say in the mental health space that our understanding of mental illness and mental health treatments is really relative to many other areas of medicine, still in its infancy. It's not very long ago that the only responses that we had available to us in relation to dealing with mental health was to either lock people up in asylums or to drug them into some sort of compliant state. And, you know, these are memories in the lives of those – of many people who have been in the treatment system still today. We now take a much broader understanding of mental health and mental illness, and we understand that mental illness and mental health issues occur not just at the acute end, but right across the spectrum of mental illness. But again, the purpose of just those few introductory slides is to really just challenge the idea that we think we know what we're doing until we get a little way down the track and realise that we've perhaps been heading down the wrong path.

So, coming to mental health specifically. Mental health, I think, in terms of government policy has been considered something of a basket case for a very long time. I know that Professor John Mendoza in his work, "Obsessive Hope Disorder", which was produced a couple of years ago now, looked back over the many reviews and inquiries that have been conducted into mental health. And I think I'm right in saying that it was something like a review every 6 to 12 months for the last 30 years. So, while we've given mental health a lot of attention and we've had a lot of difficulty in actually addressing the sorts of reforms and building the sort of systems that people require or need, we know in Australia today that one in five Australians experience a mental illness every year. And something in the order of 45 per cent or half of all Australians will experience some form of mental illness in the course of their lifetime.
As we often say, once you consider all of those people who've experienced mental health issues directly and you add to that group of people the list of people who will be supporters in some way, perhaps employers, colleagues, friends, family members and others who will be exposed to that experience of mental illness – mental illness is certainly something that affects many, many people across the course of a lifespan. We know, unlike many other forms of illness, that mental illness often manifests itself early rather than late. So the traditional or the more common sort of pathway of illness is to move from occasional illness into acute illness and perhaps chronic illness later in life. Mental illness is different from that.

We know that something like 50 per cent of all mental illness is manifested before people reach 14 years of age. And we know that something like 75 per cent of all mental illness is manifested before people reach 24 years of age. We know from recent figures that the median age of onset for anxiety in Australia today is about 11 years. We know that something like 600,000 Australians, so about one in five that I mentioned earlier, something like 600,000 Australians experience a severe mental illness each year. We know that something like 300,000 of those people experience severe mental illness that has complex needs associated with them. And as I'll come back to later in the presentation, we know that there are currently 60,000 places, so six zero thousand places, are available for people who experience psychosocial disability through the National Disability Insurance Scheme.

The purpose of giving those headline numbers is really just to say if you look at that picture, the National Disability Insurance Scheme is a very small part of the overall response to mental illness in the country at the moment, even though it's receiving a great deal of attention. And as I said, I'll come back to that. But to talk, as promised, about some of the wheels in motion as I see them in the policy space just currently that have intersecting impacts on mental illness and on our system and service responses to mental illness. We have the implementation of the government's response to the National Mental Health Commission's review of mental health services and programs. You'll note there that I've talked separately about the government's response and the National Mental Health Commission's review. So, the National Mental Health Commission conducted a very substantial review that was released eventually at the end of last year, some 700 pages or more of findings, including many, many recommendations.

We've subsequently had something like a 20 or 30 page response from the government that outlines their response to that review. So, I think it's important just to note from the outset that we're talking largely about the government's response, not about the entire review that was conducted by the National Mental Health Commission. But I'll come back to that. I'll also come back to the National Disability Insurance Scheme, the rollout and the bilaterals because I think it's very difficult to consider or to understand the mental health space at the moment without understanding precisely what's happening in that NDIS space. The impact that the governmental agreements, the agreements between the Australian Government, the Commonwealth Government and the state and territory governments, the impact that those agreements, in relation to the NDIS, are having on the broader system is fundamental on something that warrants, I think, particular attention.

But I also just want to point at as much in passing as anything else that there are a number of other very important reviews and other wheels in motion that also warrant some sort of consideration. So, as you know or are likely to know, the governments are currently reviewing the whole of the Medicare system. So a line-by-line review of Medicare items. And we would expect that that will include the sorts of items that allow the Better Access program, for instance, to deliver mental health services to people that allow GPs to deliver mental health plans to people who come through their doors. So, that Medicare review, we suspect, is one of the areas that's likely to have a pretty substantial impact on future mental health policy and programs.

Similarly, Dr Steve Hambleton, a former president of the Australian Medical Association, has conducted and handed to government a review of primary healthcare. And we know from all that's been reported in relation to that review that one of the things it's likely to point to is the particular opportunities that we have to address chronic illness through hospital in the home and primary care in the home type activities. This relates, as I'll say in a moment, to the sorts of responses that the government has made to the National Mental Health Commission's review, because one of the things that government says it will do in relation to people who experience severe mental illness is to bundle up the current raft and range of services that are available to people, to bundle them up and provide a particular intervention for people who are in severe need and in need of complex responses. We don't know exactly what that will mean yet, but it's a theme that reoccurs in a number of areas and warrants consideration here.

In terms of the other big ticket items that I think warrant consideration in terms of trying to understand the current policy environment is that the Fourth National Mental Health Plan has expired. So, we're currently without any form of national plan to govern our approach to mental health. And governments together are working on the Fifth National Mental Health Plan, Suicide Prevention plan. That process is not yet entirely in the public domain, it sort of began and had a bit of a false start and is just recently starting again. But we're expecting, come June, that the governments – so, state, territory governments and the Commonwealth Government are working together – will produce a draft and we're likely to see that draft in June that will articulate the joint response that Commonwealth and state governments will take to addressing mental health issues. I think it's important to remember, as we'll come back to that, that discussion happens in the context of the NDIS and in the context of the bilateral agreements that are being negotiated between governments about what's in and what's out of the NDIS.

It's also important to consider here that the government's response to the National Ice Taskforce also included mental health components. So one of the things that the Ice Taskforce response articulated was the need for alcohol and drug agencies on the ground and mental health agencies on the ground to working more closely together. It's also worth noting the Ice Taskforce though because the Ice Taskforce response included new money. So, some $350m, I think, of essentially new money that is being injected into the alcohol and drug treatment system and into the community organisations that deliver those services. If we're looking at working more closely together, then that's something that I think mental health organisations need to have their eye on also.

Briefly, because this list could go on and on, I think it's worth noting here that the Federation review, which seems to have lost some momentum since the change in Coalition leadership and the change in Prime Ministership from
Tony Abbott to Malcolm Turnbull. But nonetheless, the Federation review, as the papers that were released, did explicitly point to mental health as being one of the areas of Federation failures – one of the areas where Commonwealth Government relations and state government relations have allowed gaps and duplication and complication to occur in the service system. So we're not entirely sure what will happen to the Federation review, but we can be sure, I think, that whatever comes out of it is likely to have implications for mental health.

Briefly, the government have had a couple of responses into reviews and looks at welfare. And sadly, in a way, it's always at budget time that our attention turns particularly to the sorts of measures that governments might wish to take in order to reduce the number of people who are on Disability Support Pension and other forms of support because our concern rises at about this time that one of the ways in which that welfare dependency can be diminished is simply by making access to those programs harder rather than by providing the service and supports that people will need to leave welfare. So, that's something that we're sort of perhaps particularly mindful of right now at budget time. And I think it's also worth noting that right amidst all of this change, we're now readying ourselves for an election. And that's important for a number of reasons.

One is because it creates and contributes to the uncertainty and that broad uncertain environment that I talked about already. In an already uncertain policy environment, we may need to ready ourselves for further change. But it's also true and important because as we approach the election, we head into caretaker mode. And there are many, many programs that I know in recent days are still negotiating contracts for the future of services beyond July 1. We're hopeful and hoping that the bureaucracy manages to resolve a lot of those uncertainties before heading into caretaker mode when it's much harder for the bureaucracy to enter into contracts and to provide continuity of services.

I don't know how many of you are familiar with the film "The Perfect Storm", but we often talk, in my office, now about the Perfect Storm of reform that's occurring at the moment, and the difficulty and the fear and the challenge of being caught in that. If you can see the slide that's up at the moment, it's a slide from that movie "The Perfect Storm" and I started using that slide before people actually pointed out to me what actually happened to George Clooney and his colleague not very long after that. It wasn't a happy ending. I'm a bit more optimistic about where we might end through all of this reform. But nonetheless for organisations that are working in the space, I think it's fair to say that there are huge challenges and a great deal of uncertainty. That's the environment that I've tried to point to just now.

In terms of the concrete terms of the review that was conducted by the National Mental Health Commission – I intend to skip through this fairly quickly because I suspect many of you will be familiar with it – essentially, the Commission's review suggested that a very large measure of the government, the Commonwealth Government's response to mental health issues was fixed and fixed in areas that are demand-driven, like the Disability Support Pension – the biggest expenditure item that government has. And not surprisingly. And you do sometimes wonder why we need to have reviews to find these things. It pointed out that if we are to manage future growth, then essentially we have to start doing things to prevent people from becoming ill in the first place. Again, it's not rocket science.

But sadly, the mental health system has traditionally been geared towards the provision of acute and tertiary care, and has struggled to find the resources available or that would be required to provide adequate supports in the community, and has certainly struggled to provide the sorts of programs and services that might prevent people from becoming ill in the first place or that might moderate people's illness if they do become ill and prevent them from becoming more severe and a larger drain on the systems. The National Mental Health Commission went on to say, in the face of all of that, that we should redirect spending towards early intervention, and they proposed some methods for doing that. They also said that Primary Health Networks should be renamed Primary and Mental Health Networks. And the fees should be – the devices that are used, the structures that are used by government to pull funding and to drive integration at a local level. And I'll talk more to that in a moment, because Primary Health Networks are certainly a very large measure of the reforms that are available to us in the current environment.

The Mental Health Commission talked about building a stepped care approach to responding to mental health issues, which is really just to say that people need to be able to step quickly into and out of – and access the sorts of supports and programs that they need at a given time, rather than step through a sort of – a serial or a linear pathway of treatment. So, and particularly in the mental health space, the need for support is often episodic and we need to have much more agile and flexible services available to us in order to deliver. The Commission also pointed out that there are many groups who need particular and targeted services. The obvious ones, culturally and linguistically diverse populations where language and cultural issues can mean greater challenges in relation to both identifying and managing mental illness. But not constrained to those groups either, Indigenous groups certainly, LGBTIQ groups, any populations where there are particular cultural issues that might be required are amplified in the mental health space because I think there are so many cultural aspects to mental illness and the experience of mental health.

The Commission also pointed out that we need to clarify the responsibilities of state and territory governments, and that we need to manage the risks associated with the rollout of the National Disability Insurance Scheme. And that is something, again, that I'll come back to in a moment. The boundaries between what I might call the ongoing mental health system and the National Disability Insurance Scheme are as yet unclear and are only just emerging as rollout continues. But that's an area where we need to have particular attention. The Commission also pointed out that we need to boost the mental health workforce, and in particular that we need to increase NGO and sector capacity if we are to deliver on the promises of the sort of service offering and integrated service offering at a local level. And that's one of the areas that I think we might lament that we're not yet, I don't think, seeing the sorts of concerted effort that we might need in order to find and develop and support the workforce that is needed in the mental health space. If anything, year on year of uncertainty and year on year of short-term contractual arrangements, which are about to continue through primary health networks. If anything, that environment has done more, I think, to undermine the workforce, more to encourage people to move on and do work in other domains than perhaps any other factor.

So, in terms of the government's response then to that National Mental Health Commission's review, the first thing that the government did in – and you might remember that the timing of the review's release meant that it was happening right in the lead up to a co-ed gathering, and the Commonwealth ruled out any reduction in state and territory funding, which created something of a barrier to the implementation of the sorts of changes that the National Mental Health Commission had envisaged. The government also – though, clearly got on board with the idea of Primary Health Networks, including roles of step carers being the principal avenue for reform.

So what we've seen, effectively, is a consolidation of a whole raft of government programs that were previously programs that were being delivered in the mental health space are now being – or will now be delivered through Primary Health Networks. So things like the Mental Health Nurse Incentive Program, the ATAPS program, the programs like the Partners in Recovery, Suicide Prevention, programs like Personal Helpers and Mentors, programs like the carer respite for mental health carers – all of those programs have essentially been divided between Primary Health Networks and the National Disability Insurance Scheme. In the next couple of years, we'll see that rollout proceed.

The government also backed the idea of establishing a digital gateway and we haven't got a lot of detail yet about exactly what that might mean, the establishment of a digital gateway. But the idea principally seems to be around streamlining people's access to services. So, providing people with some sort of gateway through which they can get access to – a raft of either self-help services or an entrée into the service system. And also a way in which those needs can be triaged and managed more effectively. So, there are currently a range of online services and programs. Those online services and programs largely exist in isolation to each other. And they exist in isolation from the mainstream, face-to-face service offerings that people might expect to get access to. The idea of a digital gateway is to bring some of those things together.

I want to talk briefly now about the National Disability Insurance Scheme because I think it's hard to understand, as I said at the outset, hard to understand what's happening in the mental health space unless we understand a little more clearly exactly what it is that's happening in their National Disability Insurance Scheme space as well. The National Disability Insurance Scheme, I think, is most, in its simplest form, described with the idea of individual choice and control. So, disability advocates in particular, and we saw that massive campaign from disability advocates, "Every Australian Counts" ahead of the establishment of the Disability Insurance Scheme was principally around resting control for services and programs back from disability organisations who'd been delivering those services for a very long time and into the hands of the people who experience and rely on those programs.

The idea was to essentially pull the funds that were available and then on the basis of assessment to give those pulled funds back to individuals as packages of support, packages that would allow individuals to purchase the sorts of supports and programs that they might need themselves. At the highest level, that means a tier 3 package of support in which a person receives a notional allocation of funding, and with that notional allocation of funding, they are able to buy themselves a package of supports that are considered reasonable and necessary by the scheme. Obviously, as the scheme rolls out, we'll have greater clarity about what reasonable and necessary actually means. But in the psychosocial disability space, there are some particular challenges around the intersection of psychosocial supports and medical supports because the Disability Insurance Scheme is not intended to provide medical supports. Those supports are intended to be provided by the health system.

But in the mental health space, people often have a range of needs, and those needs need to be addressed holistically. So we're still wrestling with the challenge of what it means to be delivering mental health services through the National Disability Insurance Scheme. Tier 2 supports for the schemes are yet to be determined. Tier 2 supports are supports that will be provided to a range of funding that the NDIA and the government are currently considering how they will repackage it. So, it's imagined that the NDIA and my hope that capacity in this space to bulk buy services – so, rather than services being purchased by an individual who gets a notional package of care, the NDIA may buy some services in blocks or through grant arrangements. But as I said, it's unclear exactly what those yet would mean.

It's also quite clear that from the budget that's allocated in that space, I think something like 120 million, $130 million at full scheme rollout, that there's a relatively small amount of money available to fund any mental health services that will be funded through that scheme. So, as I say, if there's $130 million odd available to the whole of the National Disability Insurance Scheme for tier 2 supports, what are now called information linkages and capacity building or ILC, then, you know, on those rough numbers that only leaves something like $30 million available for those programs in the mental health space. As I've said, there are some challenges fitting the square psychosocial disability peg into the round NDIS hole. We've been strong advocates and supporters of the NDIS and we remain so. It's my view that the NDIS should be providing an excellent service for a very small range of individuals who have the most complex of needs, and that the rest of the service system should be maintained and supported in order to deliver the broad and mainstream services that people will need on an ongoing basis.

There are also some particular challenges marrying mental health and the NDIS because of the difficulty around the definition of permanent disability and what exactly that means, particularly in an environment where mental health issues can be episodic and often are episodic and needs fluctuate. But also, what it means to say that a person with mental illness has a permanent disability. Recovery practice has advanced a long way in mental health over a number of decades now and the focus on recovery is sometimes just a bit challenging, I think, for organisations to marry into the NDIS scheme. Just to finish that sort of broad piece, one of the areas that emerges from all of that discussion, in my view, is to consider the issue of indicators and targets which is to say how will we know what we have done has been successful? What are we trying to do? What are the pathways that we need to head down in order to better deliver these services?

I put this next slide up not because I expect you'll be able to read it, but really just as a reminder and as a pointer to the work that was done by the National Mental Health Commission and Mental Health Australia some several years ago now at the request of COAG to develop a framework for measuring our performance in the mental health space and a framework for setting targets in the mental health space. I think it's useful because in the current environment, as we see PHNs being rolled out and as we see the National Disability Insurance Scheme being rolled out, it's quite clear to me that we're going to have to have some agreed targets and indicators if we're going to be able to measure the effectiveness of what we're doing.

So, to briefly summarise, and this is my summary not theirs, to summarise the work around those indicators and targets, the indicators and targets are described as whole of life indicators and targets. And I think this will go back to the theme I'll come to at the end about being person-centred, because unless we are able to be person-centred in our approach, then we won't break down the sorts of silos that traditional service models have put up and traditional funding models have put up. So, the sorts of targets and indicators that were developed out of that work relate to these major themes, which is to say because of the work that you're doing, are more people with poor mental health likely to have better physical health?

That's a complex way of saying that the gap between people with mental health issues and people with other physical health issues, the mortality gap is huge. People die earlier if they have a mental illness and often die because of heart disease or diabetes or other chronic conditions that weren't picked up. So, what can we do to close the gap? Will the activity that we're conducting mean that people have better mental health and wellbeing? We don't want to lose sight of the idea that our mental health systems should ultimately be promoting wellbeing rather than simply responding to acute and poor mental health when it occurs. Will people who experience poor mental health still be able to live a meaningful and – what their National Mental Health Commission termed – a contributing life? And that then leads us to measure things like people's participation in community, people's participation in family, people's participation economically in employment and in other ways.

Will more people have a positive experience of support, care and treatment? I think again this goes to an important issue for services that are being asked to become more person-centred. We don't routinely ask people how they experienced our service. Internationally, we see a huge trend from some of the world's leading companies to ask one simple question about their performance and that question is usually some variant of, "Would you recommend this service to your family or friends?" And so I think there would be some very simple questions that we could ask about our services in order to get a better handle on people's direct experience. Will people experience avoidable harm? This indicator spoke particularly to the idea of suicide prevention, on the belief that suicide is an avoidable harm and the sorts of programs that we should be – that we are delivering – should be contributing to a reduction in suicide rates.

Sadly, we know on the back of the most recent numbers that suicide has increased in recent years, death by suicide has increased in recent years rather than decreased as we would've hoped. But finally, what is the experience of stigma and discrimination? Mental Health Australia – some years ago now, but in its former life as the Mental Health Commission – Mental Health Council of Australia, conducted an investigation into stigma and discrimination. Sadly, I found that people who experienced mental illness were more likely to experience stigma and discrimination from people who were involved in their mental health care than from the broader population. Which is telling, I think, and probably tells us a lot about the under-resourcing of the sector and the challenges that people are facing.

The sorts of questions that I think organisations need to answer then directly really relate to the reverse of those targets and indicators. And I hope these are the sorts of questions that your services will be asking. Will people live longer, people who experience mental illness, will they live longer because of their exposure to your services and programs? Will people have better wellbeing because of the services and programs that you're delivering? Will more people who experience poor mental health live a meaningful and contributing life? So, are your services and programs connecting them to their communities? Are people having a positive experience of treatment, care and support that they receive through your organisations, and do you routinely measure that and do you routinely compare that to the performance of other organisations?

Do you reduce suicide? Are people avoiding the harms associated with unclear referral pathways or forgotten pathways or people not being handed appropriately to other services? And will people experience discrimination in your service? And will your service help to breakdown discrimination more broadly as it occurs in the community? Briefly, what does this mean then for NGOs? And I think there are a whole raft of reflections that we could make about what the whole uncertain and rapidly changing environment means for non-government organisations in particular working in this space. I think it means that there's likely to be a much greater emphasis on individual choice and control. So, I think one of the reasons why the NDIS is so important in the current environment is not because of the NDIS itself, but it's because of what the NDIS means for future services and programs.

I think the idea of individual choice and control, the individual packaging of services, the individual management of budgets for programs is a journey that's now well and truly out of the bottle. And I think many grant-based services that we run today will slowly – and, I mean, in some cases, perhaps quickly be converted into packages that can be bundled up and delivered through individual packages of support. I think we're likely to see a focus in the short-term at least on this idea of regionalisation and commissioning. The Primary Health Networks are the most clear example of that, even though there are only 31 of them nationally. Some would argue that that doesn't lead to a very local flavour for some PHNs that might be bigger than England, for instance. Nonetheless, I think it's a Commonwealth Government sort of direction that greater regionalisation and greater local control will be part of those services.

I think we'll see in this changing environment much greater competition from non-traditional providers, from services that have not delivered services in this space previously. And I worry that some of our organisations will not be well placed to compete in the short-term at least because of the challenges that presents. I think there'll be greater analysis and scrutiny regarding the quality of programs. I have some fears, actually, that in the short-term at least, the rush to get services and programs on the ground may actually see a diminution of quality. But ultimately, in a system that is more dominated by the individual experience of people in need of services, then I think public scrutiny regarding the quality of services will be much more appointed.

For organisations, I also think it means that there are much greater challenges and pressure on the infrastructure that you provide, in particular the idea of data collection, and, as I'll say in a moment, performance measurement. NGOs are traditionally underinvested, underinvested in precisely the kinds of infrastructure that they now need in order to demonstrate the value of their services. I think there's also likely to be, because of that notion of individual choice and control, a much greater requirement for organisations to co-design services hand in hand with the consumers and carers who will experience them. I also think that in the transitional arrangements, many NGOs will be challenged and threatened by the simple cash flow arrangements that can result from these sorts of transitions. So, if we're moving from a world in which organisations received a block grant with an upfront payment that we then ask to deliver services and programs that were ultimately acquitted at the end of the year.

If we're being asked to move out of that environment into an environment where NGOs must establish services, train staff, maintain premises, attract consumers and carers to their services, deliver those services and evaluate them and then subsequently, upon invoice perhaps, receive a payment for those services. But I think the financial pressures on organisations is going to be great, particularly on smaller organisations and those that don't have substantial reserves. And then finally, I think a greater emphasis on performance measurement because in a distributed commissioning environment is going to be challenging for many organisations to find themselves in a position to make the case to their local PHN that the sorts of services and programs that they can offer should be purchased.

I think it's going to be hard for organisations to make the case that the sorts of programs and services that they deliver have been effected – have been effective, rather, when measured against those sorts of performance targets and indicators that are mentioned earlier. It's not all bad. As I said at the outset, we need to be careful what we wish for in a way. I think there's a lot of confusion in the current environment. Some of you have perhaps seen me use this slide before, which I hope, again, generates the virtual chuckle that we might've started with. But I think there's truth in this slide as well, as the whale in the picture is wondering how it is that he's ever going to evolve if we keep getting pushed back into the ocean.

I think we need to be carefully considering, in the current environment, what it is that we really do need to preserve in the current environment, what needs to be pushed back into the water or kept alive and what it is that we can allow to flounder and die on the beach. If I can just briefly have you remember those slides right at the outset about the fancy new computer, the doctor's advertising their cigarettes, the drugs that were being used as the main line of action on mental health issues right at the start. I think we might end up surprised in 10 or 20 years by the things that do survive and the things that change. We need to embrace the current environment, I think, by embracing the idea of measuring our performance and comparing our performance against the many other options that people have on board. So, I might leave my formal presentation there. I understand that we have an opportunity now, perhaps, for some questions that people may have submitted during the discussion and I think our chair will also point us to perhaps some information about an ongoing opportunity that we have to exchange questions and answers over the next little while.


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Slide outline: Mental health reform at the crossroads
  1. Mental health reform at the crossroads
    • @FrankGQuinlan
    • CFCA information exchange webinar series, Australian Institute of Family Studies - April 2016
    • Mental health Australia: Mentally healthy people, mentally healthy communities,
    • The views expressed in this presentation are those of the presenter, and may not reflect those of AIFS or the Australian Government.
  2. Today’s discussion
    • Discuss the various policy "wheels in motion”
    • Discuss the changing funding environment
    • Discuss the changing philosophical approach
    • Discuss the implications for NGOs and others working in related sectors
  3. Image: Vintage newspaper advertisement
    • 10-megabyte computer system only $5995 complete. IMSAI …Thinking ahead for the 80's
  4. Image: Vintage magazine advertisement that reads "More doctors smoke camels than any other cigarette"
  5. Image: Vintage magazine advertisement that reads "Now she can cook breakfast again …when you prescribe new mornidine"
  6. Image: Vintage magazine advertisement that reads "For the prompt control of senile agitation…Thorazine. Thorazine can control the agitated, belligerent senile and help the patient to live a composed and useful life."
  7. Image: Roadside domestic wheelie rubbish bin with grafitti "Fix mental health"
  8. Wheels in motion
    • Implementation of the Government response to the National Mental Health Commission’s Review of Mental Health Services and Programmes
    • NDIS rollout & bi-laterals
    • Medicare Review
    • Primary Health Care Review
  9. More wheels in motion
    • 5th Plan for Mental Health and Suicide Prevention
    • Ice Taskforce response
    • Federation Review
    • Welfare Review (McClure, Forrest)
    • Election readiness
  10. Image of sailors guiding ship in heavy storm.
  11. National Mental Health Commission Review Key Findings
    • The Commonwealth Government’s $9.6 billion in mental health spending is dominated by acute care funding for states and territories and demand driven expenditure like the Disability Support Pension
  12. National Mental Health Commission Review Key Findings
    • "If future growth in costs is to be managed, the key focus has to be on these programmes… The risk management strategy which is most likely to be effective in relation to all these programmes is to stop people needing access to them in the first place.”
  13. National Mental Health Commission Review Key Findings
    • Redirect spending to early intervention
    • Use PHN’s (PMHNs) to pool funding and drive better integration at the local level
    • Building a "stepped care” approach
    • Ensure targeted support to specific communities
  14. National Mental Health Commission Review Key Findings
    • Clarify Commonwealth/State & Territory roles and responsibilities
    • Manage risks associated with the transition to the NDIS
    • Boost mental health workforce and increase NGO sector capacity
  15. National Mental Health Commission Review Government response
    • Rule out reduction in state/territory funding
    • Roll out reforms via Primary Health Networks (including stepped care)
    • Establish Digital Gateway
  16. National Disability Insurance Scheme
    • Individual choice and control
    • Tier 3 packages of "reasonable and necessary” support
    • Tier 2 supports yet to be determined
    • Challenges fitting the square psychosocial disability peg into the round NDIS hole
    • Challenges to unpack "permanent disability” with episodic illness and "recovery” practice
  17. Indicators and Targets
    • Model from National Targets and indicators for mental health reform - the COAG Expert Reference Group
  18. Indicators and Targets
    • More people with poor mental health will have better physical health and live longer
    • More people have good mental health and wellbeing
    • More people with poor mental health will live a meaningful and contributing life
  19. Indicators and Targets
    • More people will have a positive experience of support, care and treatment
    • Fewer people will experience avoidable harm
    • Fewer people will experience stigma and discrimination
  20. Question for services to answer…
    • Will more people with poor mental health have better physical health and live longer because of your service?
    • Will more people have good mental health and wellbeing?
    • Will more people with poor mental health live a meaningful and contributing life?
  21. Question for services to answer…
    • Will more people will have a positive experience of support, care and treatment?
    • Will fewer people will experience avoidable harm?
    • Will fewer people will experience stigma and discrimination?
  22. What does this mean for NGOs?
    • Greater emphasis on individual choice and control
    • Greater regionalisation of commissioning
    • Greater competition from non-traditional providers
    • Greater public scrutiny regarding quality
  23. What does this mean for NGOs?
    • Greater pressure on infrastructure
    • Greater requirement to co-design services with consumers and carers
    • Greater pressure on financial management
    • Greater emphasis on measurable performance
  24. Image:  Cartoon of a beached whale commenting to people pushing it "How are we ever going to evolve if you people keep pushing us back into the ocean?" as a fish walks past on four legs.
  25. Mental health reform at the crossroads
    • @FrankGQuinlan
    • Join the Conversation
    • You can continue the conversation started here today, and access a range of related resources, on the CFCA website:

This webinar was held on 27 April 2016.

Mental health reform is at an important crossroads.

At the Commonwealth level, on the one hand, a range of mental health programs are being subsumed in the move toward the NDIS. On the other hand, many of the remaining Commonwealth mental health programs are being de-centralised by transferring funding to Primary Health Networks who will be responsible for commissioning services at the local level.

This transformation represents more than a shift in funding arrangements. Reforms are intended to advance:

  • Individual choice and control;
  • Local planning and integration; and
  • Support for innovation.

This webinar examined the current “wheels in motion” as Commonwealth reform processes unfold.

It also examined the implications for other service sectors, as Commonwealth reforms seek to influence service models in related service sectors.

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Further reading and resources

 The feature image is by Shandi-lee Cox(link is external) CC BY-NC-ND 2.0(link is external) .

About the presenters

Frank Quinlan

Frank Quinlan is the CEO of Mental Health Australia, the peak body representing mental health organisations in Australia. Frank is responsible for implementing Mental Health Australia’s vision of "better mental health for all Australians".

Frank was previously the Executive Director of Catholic Social Services Australia, a peak national body for social services organisations providing social and community services to over a million people each year.