Written by: Sebastian Rosenberg, Fellow, Centre for Mental Health Research, Australian National University
Victorian Premier Daniel Andrews has promised to hold a royal commission into mental health if Labor wins the November state election. Last week’s announcement comes a couple of weeks after the federal government asked the Productivity Commission to inquire “into the role of mental health in the Australian economy and the best ways to support and improve national mental well-being”.
The recently established Royal Commission into Aged Care Quality and Safety is also likely to deal with mental health care in residential care settings.
Inquiries are not new in mental health. There were 32 separate statutory inquiries into the sector between 2006 and 2012 alone, typically gathering first-person experiences. Despite years of stories and recommendations, very few, if any, have been implemented.
Storytelling in mental health is often traumatic. Healing comes not just with recognition but also through genuine action. If there must be a new inquiry, perhaps what is really needed is a community review into the failed implementation of mental health reform.
In 1983, New South Wales released a report from the Inquiry into Health Services for the Psychiatrically Ill and Developmentally Disabled (also known as the Richmond report), which consisted of 400 pages and 102 recommendations. One of these was the establishment of multidisciplinary community mental health teams. Yet, to this day, the vast majority of state-funded mental health services are still provided as either hospital inpatient, outpatient or emergency services.
In 1993, more than 450 witnesses shared mainly personal stories during the National Inquiry into the Human Rights of People with a Mental Illness. This was established in response to reports these rights were being ignored or violated. The 1,008-page report had more than 100 recommendations, which included that mental health care occur in the “least restrictive” setting.
Change in this area has been slow. Mental health patients endured seclusion close to 12,000 times and physical or mechanical restraint 13,000 times in 2016-17. And 22 people died in Victoria between 2011 and 2014 while in mental health inpatient units. Such incidents occur regularly across Australia, leading to yet more inquiries, such as the Inquiry into the Management of Health Care Delivery in NSW, which released its report in September 2018.
People again told their stories in 2005 as part of an inquiry into Experiences of Injustice and Despair in Mental Health Care in Australia, conducted by the Human Rights and Equal Opportunity Commission and the Mental Health Council of Australia. The aim was to assess the system’s performance against published national mental health standards and promote greater accountability. The 1,006-page report came with 26 recommendations, which included better funding for mental health.
Perhaps in contrast to what the community might think, this recommendation has also not been actioned. In 1992-93, the first year of the National Mental Health Strategy, mental health accounted for 7.25% of the total health budget. In 2015-16 this was 7.67%. That’s a negligible increase and quite out of proportion with the 12% contribution made by mental illness to the total burden of disease.
In 2006, the Australian Senate conducted another inquiry to assist the Council of Australian Governments’ consideration of mental health. More stories were told and published. The 600 pages and 13 recommendations included advice for national investment in up to 400 new community mental health centres across Australia – again a proposal left unfulfilled.
More recently the National Mental Health Commission’s 2014 Contributing Lives Review produced a 1,000-page report with 25 recommendations. One of these suggested that A$1 billion of growth funding (over five years) earmarked for hospital-based mental health services be redirected towards regional services provided in the community.
Where to focus
In recent years, almost all Australian jurisdictions (except the Northern Territory and Tasmania) have established mental health commissions. These are not all the same, but they do share common functions – to drive reform and improve accountability in the sector. How these bodies work with other “special” commissions is unclear. One job could be to ensure recommendations are fulfilled, but this is not a role they currently play.
Looking back on reports over the years, high-value targets include:
early intervention (with a focus on children and youth) in any episode of illness
better access to mental health support in regional areas
safety, including ending seclusion and restraint (as promised in 2007)
putting people and families at the centre of care, including in policy and planning
building non-hospital alternatives, particularly for acute care but also across the whole service spectrum
empowering the community sector to manage psychological and social rehabilitation, housing, social welfare, employment and education support
using new technologies to improve the access, quality and accountability of care.
Royal commissions often investigate impropriety and apportion blame. But impropriety is not the issue. The key challenge in mental health is finding the political will and the financial, community and professional resources to do what has already been described in thousands of pages and hundreds of recommendations.
Consumers, carers, health professionals and service providers could interrogate politicians, past and present, as to why they have spent so much time (and money) finding out what needed to be done in mental health, only to ignore the advice they received.
Sebastian Rosenberg has provided consultancy services to several mental health commissions.
Ian Hickie receives Research Fellowship funding from the National Health and Medical Research Council. He was a Commissioner of the National Mental Health Commission from 2012 to 2018.