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Senate Select Committee on Health
26/08/2015
Health policy, administration and expenditure

FRKOVIC, Mr Ivan, Deputy Chief Executive Officer, National Operations, Aftercare

HOPWOOD, Professor Malcolm, President, The Royal Australian and New Zealand College of Psychiatrists

MELDRUM, Mr David Macmillan, Executive Director, Mental Illness Fellowship of Australia

PETERS, Mr Andrew, Chief Executive Officer, The Royal Australian and New Zealand College of Psychiatrists

QUINLAN, Mr Frank, Chief Executive Officer, Mental Health Australia

ROSENBERG, Mr Sebastian, Senior Lecturer, Brain and Mind Centre, University of Sydney

RUTLEDGE, Ms Pamela, Chief Executive Officer, RichmondPRA

ACTING CHAIR: I now welcome everybody to our first round table of mental health peak bodies and service providers. Thank you all for making the time to talk to us today. Do any of you have any additional comments to make on the capacity in which you appear today?

Ms Rutledge : I am also the chair of the national Partners in Recovery organisation reference group. I do not formally represent the reference group, but I am here and able to speak from the perspective of Partners in Recovery, as I understand there is an interest in that.

Mr Frkovic : I am here as part of the MIFA group.

ACTING CHAIR: Thank you very much. I definitely feel like I am in good hands. I invite you to make a brief opening statement, and then the committee will ask questions.

Ms Rutledge : Thank you very much, Senator. The organisation that I primarily represent is a large mental health community organisation operating primarily in New South Wales and south-east Queensland. We provide a whole range of services to help people with a mental health issue stay well, stay independent in the community, learn new skills and get employment. One of the key programs that we are involved in is the Partners in Recovery initiative. This was an initiative of the Commonwealth government in 2012, and it is important for its capacity to provide ongoing infrastructure and support to people with a serious and persistent mental health issue. We hope to be able to evolve into a role in the National Disability Insurance Scheme.

We wanted to particularly draw the program to the senators' attention because it has been somewhat misunderstood historically. It is a large program funding consortia across Australia to deliver what is called 'support facilitation' to people with a severe and persistent mental health issue. It has had the impact of bringing together a very wide range of organisations, not only specialist mental health providers but primary care organisations and other organisations working in the community in a different way to reach out to people who have fallen through the cracks and who have missed out on services or have been poorly treated by services in the past. The Commonwealth has invested significant money in this infrastructure, and there is an opportunity to enable it to evolve—with some modifications, of course, and potentially some different use of money—into a role in the National Disability Insurance Scheme as a special supporting arrangement for people with a severe and persistent mental health issue. As service providers on the ground, our plea to government—through you, Senators—is that we do not throw away the investment that has gone into creating these consortia, which bring together organisations that are now in a position to provide ongoing support to people who have historically missed out on mental health support. Thank you.

ACTING CHAIR: Thank you.

Mr Quinlan : I have tabled an opening statement and, with your indulgence, I will just speak to it rather than bore you by reading the details. I think the main interest from Mental Health Australia is really that there are a number of processes happening at once that are affecting the mental health space. The National Mental Health Commission have produced their comprehensive Review of Mental Health Programs and Services, and we are awaiting the government's response to that review, but at the same time we have the government in multilateral negotiations with state governments over the Fifth National Mental Health Plan—with the end of the Fourth National Mental Health Plan, we are coming into the Fifth National Mental Health Plan. At the same time, the government is in bilateral negotiations with each state and territory on arrangements for the National Disability Insurance Scheme, which, as Pam has just indicated, has implications for the sorts of services and programs that are transferred into the NDIS and the programs and services that remain outside the NDIS. At the same time, the government is reviewing primary healthcare arrangements, which are currently under review, but also, at a macro level, reviewing arrangements around the Federation in the Federation white paper process.

So I do not think we have ever experienced a time when there were so many wheels turning all at once, but I guess the great irony—the bitter irony—of all of that is that that has resulted in a great deal of inaction in the mental health space. We have really been on hold, largely, in terms of major policy decisions since the government commenced their Review of Mental Health Programs and Services. Beyond the temporary extension of certain programs just to keep the doors open a couple of times during that period, there have not been substantial reform measures undertaken—this at a time when, I think it is fair to say, there has never been greater unity or clarity from a very broad and diverse sector about the need for reform and, in large measure, about the steps that are required in order to undertake that reform. I am sure we will explore that a bit more as we go on.

The key points of our concern are, though, that I think we need to ensure that there is a true partnership between government and non-government providers, because I think it is fair to say that non-government providers do not yet feel especially engaged in the reform process, and ultimately they will be the ones that are required to implement it. We need to have some clarity about why it is that the mental health system continues to be outside the NDIS, and I suspect my colleague David Meldrum from the Mental Illness Fellowship will touch more on some of the details about our concerns about who is in the NDIS and who is outside the NDIS. We have some concerns also about the primary architecture of Primary Health Networks. There is a large measure of agreement about the need for us to localise programs and to pool programs, but there are some concerns that the arrangements for Primary Health Networks do not yet give us confidence that they are going to be the best channel to undertake all of the work that has to be done in the non-medical, non-clinical space if we are going to address mental health properly.

Finally, I will just say that, through all of this, I think we need to be doing a much better job of ensuring transitional arrangements. This is not a problem for the future. As at today, if one of our agencies loses a staff member in, say, the Partners in Recovery Program, it can only offer a replacement staff member an eight-month contract with an uncertain future beyond that. That means that, as at today, the sorts of programs and services that we are delivering to people on the ground are starting to deteriorate again, because of the uncertainty of the arrangements beyond June next year. That is something that I think we need to be doing much more work on, and we stand ready to assist government and other interested parties to develop that work. I am happy to take further questions as we go on.

ACTING CHAIR: Thank you, Mr Quinlan. Before we go any further, does the committee agree to receive Mr Quinlan's opening statement as a tabled document?

Senator WILLIAMS: Yes, certainly.

Mr Rosenberg : Thanks, Senator. Thanks again for the opportunity. I also want to acknowledge the role of this parliament and its enduring interest in mental health, particularly the Senate. The Senate has inquired into mental health previously, as you would know. The sector really appreciates the level of interest and accountability and scrutiny and concern for the issue of mental health that the Australian Senate in particular has shown to mental illness and people with mental illness over many years. Thank you. I also thought it was worth reflecting, as people talk about a fifth mental health plan, about where we got to and what we have received, if you like, in the ensuing 20 years since 1992 when we had our first mental health plan—so this may be slightly controversial.

Despite four national plans and two national policies, one road map, two report cards and one action plan, genuine mental health reform seems as far away as ever. There is a sense that things have changed and that the asylums have closed in Australia. Well, there are still 1,831 beds in asylums across Australia costing about half a billion dollars per year. Large elements of the old system are still very much in place in our current system.

The initial plans were looking for national fairness and consistency, but in fact the experience of care varies wildly depending on where you live. The seven day community follow-up rate on discharge is 72 per cent in Victoria and 48 per cent in New South Wales.

People in the sector were really hoping that the policies would reflect the interests of clinicians and consumers and carers and service providers, but in fact the policies have been led by health bureaucrats in each of the nine departments and have become less relevant to the interests of the sector.

There was a very strong emphasis at the start on clear accountability—and I know Senator Williams has already asked about how we know certain things. The answer is: we largely do not know about the impact of the $7.6 billion we spend on mental illness in Australia. Prime Minister Howard, Premier Iemma and then subsequently Prime Minister Gillard all promised some long-term, organised reform around mental health in order to try and establish some accountability, and that has not occurred. Instead what we have had are some piecemeal and sporadic changes with some good ideas and some good programs, some of which people are now anxious not to lose as other changes arise.

People were interested in not separating this part of the body from that part of the body and in having holistic care, but instead we still very much have care by body parts or disease types.

People were interested in consumer-carer feedback in driving system quality improvement, but instead we have clinician-rated arrangements which fail to really impact on service quality improvement.

One of the main things that was through all the history of Australian mental health policies and plans has been the desire to establish community-based mental health care, but in fact what we have is an extremely hospital-focused system of care. Even when the National Mental Health Commission suggested a very small change to those arrangements, Minister Ley unfortunately seemed to indicate that that would not be pursued.

People were interested very much in joined-up services, but in fact we have a Commonwealth-state split based very much on who pays and not what works—and that moves beyond health care to include social services and housing and community services and other areas.

We were interested very much in promotion, prevention and early intervention, but in fact we have a system which really is about postvention and crisis management.

We were very much interested in e-mental health technologies, some of which Australia has led in, but in fact what we have is a continued dependence on face-to-face care and fee-for-service type approaches.

There were 32 separate inquiries into mental health between 2006 and 2012. Here is the Senate's recommendations from 2006. They were excellent. The reform of mental health care really depends on filling the gap between the GP and the hospital. There needs to be an establishment of good community mental health services, and this was a key recommendation that the Senate made in 2006. The issue here is that nobody owns community mental health. It falls between the federal government and the state government in terms of responsibility .Nobody has a leadership role, so I am putting up a 'position vacant' sign.

It is also worth mentioning that, despite recent changes to funding arrangements and so on, the mental health share of the health budget is in decline. The mental health system remains in crisis. New funding into existing failed systems is a terrible idea. What we need is a new approach based on genuine community access to mental health care which combines both clinical and non-clinical elements of support.

Mr Peters : Professor Hopwood will explain the broader view from the college perspective, but I thought I would speak about one of the largest investments made in psychiatry that this government and the previous government made and the need for this to continue. I commend the governments for investing in the shortage of psychiatrists that currently exists.

The Specialist Training Program is a highly valued initiative within the college of psychiatrists that is significant and essential to psychiatry training. It aims to match the nature of demand and reflect the way health services are delivered in Australia. The training program currently funds posts that otherwise would not exist. These posts provide an expanded training environment and also contribute to mental health service provision. The college has also received funding for sustainable support projects that aim to support trainees and specialist international medical graduates on their pathways towards fellowship. The project commenced in June 2009, and the college is currently in the process of finalising the latest deed. The total funding payable in relation to training of psychiatrists is somewhere in the vicinity of $100 million over that period. It finishes in February 2017.

We currently have contracts with over 80 health services and practices across Australia to achieve the target of 160 full-time employees. It offers a salary contribution to these full-time employees. Approximately 30 per cent of these posts have a component of their work that is done in a rural or a remote area, which is critical. These posts attract a rural loading so that we can provide some incentive. Approximately 50 per cent of these posts have a component of work that is done in a private setting, and private settings attract a private infrastructure and clinical supervision allowance. The posts range across a variety of subspecialty areas, in particular Aboriginal and Torres Strait Islander mental health, drug and alcohol addiction, child and adolescent, consultation liaison, general adult and perinatal and infant.

We have also implemented a number of support projects, and these are critical. These include a recruitment into psychiatry initiative, which is targeting student membership in a category which has somewhere in the vicinity of 1,300 to 1,400 members already, a rural psychiatry project, which has educational grants to support rural trainees in attainment of fellowship, a mentoring program for over 25 rural trainees to receive support from fellows and mentors, peer support groups for rural trainees for networking and exam preparation. We also have specialist international medical graduates support, which offers one-on-one coaching grants to support these individuals on their pathway to fellowship. Without going further into it, I and we as a college commend the governments. This is an enormous investment that hopefully will continue to be a good news story. We do have a shortage of psychiatrists. This is one particular, large investment by this government and previous governments and, we hope, future governments to achieve what needs to be achieved in this sector.

Prof. Hopwood : I will bring some broader comments from the college, if I may. The College of Psychiatrists is an organisation of about 5½ thousand members and represents over 95 per cent of psychiatrists in Australia and New Zealand. It is responsible for the training and continuing professional development of psychiatrists across Australia.

I want to start my remarks by acknowledging the work of the Mental Health Commission in their review and to indicate our overall support for the directions in that review document. There are a few items from it that we think are particularly worth highlighting. The mental health system continues to experience both great stress and great difficulty in meeting the needs of the population. Twenty per cent of the population suffer from mental health disorders in any 12-month period, and, at the very best estimate, we are providing some sort of service to under half of those. Clearly, the kind of service required varies greatly, depending on the nature of the problem, and does not always involve psychiatrists—please, do not get me wrong!—but we are way short of the target. We are particularly way short of the target in rural and remote areas and, I think we should note, in the Indigenous population, where the suicide rate is twice that of the rest of the population and is amongst some of the most concerning aspects, I dare say, of health care across the nation.

We support strongly the commission's focus on not just integrating clinical services across the spectrum, as has already been highlighted, but linking them to services like housing. It is very difficult to improve mental health in the face of inadequate housing. We particularly support the review's and other commentators' focus on bringing things together across the sector. Mental health funding is diverse in its origin, and that is a significant barrier to improving mental health care. By this, I mean not just governmental boundaries but also boundaries across the primary, secondary and tertiary sectors. We support strongly the idea that it is an important focus within the Primary Health Networks that they act to facilitate a smooth transition and the delivery of the right care for the right person.

We would particularly like to draw the committee's attention to the issues of physical health in relation to that junction, noting that individuals with mental illnesses like bipolar disorder and schizophrenia in Australia die, on average, 14 to 23 years younger than the rest of the population. That is something that is not acceptable. The majority of that premature mortality is due to poor physical health—a proportion due to suicide, but the majority due to poor physical health. We feel that a significant contribution to that is the failure to take that issue seriously and to meld together the different layers of the system in being responsible for that outcome.

The role of clinical services remains very important. As we have diversified what we do in mental health, the role of community mental health, which was the key platform in the early mental health plans, has actually fallen back, in our view, over the last decade. Part of that is about the funding division and who is responsible for community mental health. But, if we are to achieve what was hoped for with community health reform, community mental health will continue to require support.

We also feel that in-patient care remains an important component of the mental health system and we see little or no evidence that current in-patient services are quiet, lacking in work or lacking in demand by people with difficult problems. We perceive that, if our early intervention and community services improve the situation, over time it may be possible to further reduce the numbers of beds, noting there has been a very significant reduction over the last two decades. But we are concerned that if we move too quickly we will exacerbate an existing problem.

I would like to draw attention to two aspects of the Medicare system. We see the Medicare review as a very important opportunity, although we suspect that mental health has not been the primary focus or instigator of the Medicare review. We acknowledge that the current Medicare structure does not necessarily facilitate interchange between the primary and specialist sectors and that the range of item numbers available for both consultant psychiatrists and GPs, as well as allied health professionals, may not necessarily mean that we are best using those resources, and we would like the review to give serious thought to that area. As a subset of that review, some recent changes that have been tabled in relation to the Medicare safety net do cause us some concern. In particular, they involve those people who require intensive treatment that currently may only be available for some disorders within the private sector. A relatively small number of individuals will be affected, those who are seen many times in one year. They are usually people with very high needs, and the changes will result in a significantly greater out-of-pocket cost. A submission is available on that, if required.

Finally, in closing, we have already heard about the Fifth National Mental Health Plan. We very much support the need for a new national mental health plan but very much more support a new national mental health plan that achieves something. The creation of a national mental health plan that perhaps says the same things but is not associated with some of the structural reforms we think are required is probably not, we think, ultimately of much value as perhaps suggested previously. We would really like the National Mental Health Plan to help address some of these structural issues and to involve broad consultation across the sector, to really lead us further down the path of reform that we are obviously all seeking. Thank you.

Mr Meldrum : I am going to concentrate mainly on the NDIS, as Frank correctly predicted. Just briefly, the Mental Illness Fellowship of Australia at the moment is 10 organisations, with about 2,200 staff, operating out of about 150 locations across Australia. Our core strength is our work with people with severe and persistent mental illness, although we do much more in a whole variety of areas. For instance, Aftercare have got four headspace centres they run, and we are partners in a lot of those. Although our reach is reasonably broad, our core strength is severe and persistent mental illness, which is why, with the Partners in Recovery program that Pam was talking about, we are on the consortium of, I think, 28 of the 48 Partners in Recovery programs across Australia.

I want to talk about the NDIS. First of all, when in 2011-12 the debate was going on about whether psychiatric or psychosocial disability would be included in the scheme, there was a lot of unanimity across our sector that we had an unfinished job that this offered a chance to finish, which was in relation to the final group of people who, through deinstitutionalisation, have both enduring mental illness and complex, severe disabilities which are largely continuous. We have never done a good enough job in Australia of providing the comprehensive, ongoing—lifelong if necessary—support that they need. We all know that. A variety of state governments have made efforts. Probably New South Wales and Victoria are the best in Australia, but every state has done something for some hundreds or even, in a couple of cases, more than 1,000 of such people. But we have not really touched the last 50,000 or so of those people in the way that they need to be with services that are guaranteed for as long as they need them. So we welcomed the scheme, provided that it was workable, and there have been lots of debates about that. There is lots of controversy about the term 'permanent disability' and there is lots of controversy about the insurance model and the funding in arrears and the eligibility processes. That is inevitable with any new scheme, and we are working our way through those, and I think the National Disability Insurance Agency, is, with goodwill, trying to work those things through with the sector to make sure we can work the scheme right.

I want to concentrate, though, not on the 56,000 people who we think will be eligible for that but on the several hundred thousand people who will not be eligible for that scheme. The reason I want to concentrate on them is that a lot of the money that is going to those several hundred thousand people is actually being rolled into the scheme to look after 56,000 people. How many hundred thousand people have severe and persistent mental illness in Australia? You could get an argument going between any two people who study this. The most conservative estimate was from PricewaterhouseCoopers when advising the Productivity Commission about how many people might be eligible for the NDIS, back about three years ago. They said they were 480,000 people in Australia with severe mental illness, of whom about half had severe and persistent mental illness and of whom 56,000 fitted that definition of severe and persistent mental illness with profound ongoing disabilities of a complex nature.

So we are talking about well over 400,000 people—by the most conservative estimate; some people would say the figure is something like 600,000—who access services because they need them desperately from time to time, maybe not continuously in the way that that last 56,000 people do, but from time to time they and their families need them desperately. They currently access a range of clinical services, but I am particularly concentrating here on the funding for the services in the non-clinical area—things like Partners in Recovery, Personal Helpers and Mentors, day-to-day living programs, respite care for carers, a whole range of programs that are funded by the Commonwealth and a whole range of programs that are funded by every state and territory. In the case of the Commonwealth, all of the dollars for all of the programs I just mentioned have been rolled into the NDIS. The problem is that the majority of the clients of all of those programs will not get a service under the NDIS, so we are effecting a sort of two-card trick here, in which a lot of people are going to find there are a lot of wrong doors for them from next 1 July.

For the people we are trying to assist—and across our MIFA membership we are dealing with about 10,000 people at any given time—we think about 8,000 of those 10,000 will find the door closed next 1 July. We can have arguments with the NDIA about that. We do not want them to mission creep. We do not want them to start diverting the funds in the NDIS to people who do not fit that definition of extreme mental illness and extreme disability, because that sort of mission creep has happened time and again in mental health, where money designed for people with the most severe need drifted into a wider target group. So, we do not want them to mission creep, but we also want it to be recognised that if we leave things standing as they are and we do not find some way to maintain the current programs while implementing the NDIS we are actually cutting several hundred thousand people out of the existing services from next 1 July.

Mr Frkovic : I would just like to add to a few of those things from a service delivery perspective. Aftercare is a national mental health organisation operating primarily across New South Wales, Queensland, Western Australia and Victoria. We provide a range of community non-clinical services, as they are called, as well as clinical services through our headspace and early-psychosis services. We are probably one of the largest providers of PHaMs—Personal Helpers and Mentors—across the country. We are also one of the largest players in terms of Partners in Recovery. We are also a lead agency in all of those locations, and we have experience as both a player and a lead. So, we certainly have some interesting learnings from that. We are also one of the largest providers of headspace services, including early psychosis. We have four in Queensland. We also provide a range of residential services, both step-up and step-down, for people needing to exit hospital but also people who need to avoid hospital admission. So, we have a range of those services.

What I am going to say to you today comes from the experiences of particularly consumers, carers and families we are dealing with every day as a result of this changing environment, which I think we have heard all the speakers talk about here this morning. There is a real concern about the introduction of the NDIS around people with psychosocial disability or psychiatric disability—whatever you want to call it. There is a concern because the feeling is—and the analogy that I think has been used around the NDIS—that it is like a plane taking off while we are still building it. In fact, I think it is worse than that: a plane has taken off while we are building it but we are taking parts of a system that has been working relatively well—not perfectly, but relatively well. So, I think there is a real danger that we could have both systems fall over, I suppose, because you are taking parts off one system to build another while you are flying. I think there is a real danger in that, and I think families and consumers and carers feel that on an everyday basis, particularly regarding the uncertainty around the NDIS and how many people will qualify.

People are really concerned that existing services, such as Personal Helpers and Mentors and Partners in Recovery, which are helping them to maintain lives in the community to some level and degree, will disappear. Some of them will qualify for an NDIS package, as I think David and other speakers here have said. Our estimate is that probably between 70 and 80 per cent, particularly Personal Helpers and Mentors, potentially will not qualify. We have heard all sorts of figures, but we can tell you from our experience—and Aftercare is involved partially in the Newcastle pilot and in the Western Australian MyWay pilot, so we have experience across both of those—that they are slightly different, and there are pros and cons in each. But I think from a psychosocial disability perspective there are some real challenges for people who are trying to get into that system and who are existing Personal Helpers and Mentors participants to actually get a package.

This is creating uncertainty at the moment and increasing anxiety and levels of relapse amongst people, because they do not know, as I think has been said. A lot of these programs are due to finish in June next year: 'What happens beyond June? Where do I go?' So, it is creating problems for the participants themselves—the individual consumers—families and carers. They are saying, 'What do we do in this situation?' But also, as was raised earlier, by Frank and others, we have staff who are really struggling in terms of what happens to them. When you think about it, we have 450 staff, and a lot of people are wondering what happens beyond June next year. That whole system that is currently working is being unravelled from a whole range of perspectives, which I think is causing us some major challenges in terms of ongoing support for people with mental illness, and their families.

What we are also seeing—and we have certainly had discussions with the various state governments—is that as a result of this more people are going to emergency departments and more people are ending up in fairly expensive and scarce inpatient beds. I spent most of my life in the public mental health system before I came to Aftercare, so I have the experience of working on the other side. I think there is a real danger that if we unravel the current system and only a certain number of people qualify for the NDIS then the biggest pressure will be felt in the public mental health system, particular the inpatient and ED services. That is certainly the indication so far.

Just to round this off: as I said, I have spent most of my life in the public mental health system. I was involved in some of the national mental health plans and a whole range of things, so I certainly have some background in that. But the biggest experience I had was more recently, when I was involved in Queensland in establishing the Mental Health Commission, and I consulted with over 2,000 people across the state. The fundamental message coming from families and carers—and this is what I think we as a system, as governments and other people need to hear—is: 'More of the same. No, thank you.' We talk about more doctors, more nurses, more beds, more NGOs et cetera, but that is the fundamental message I would like the Senate to hear, as well as colleagues here, and the parliament of Australia. It is not working. If you talk to consumers, families and members, the current system is not working for them. We do not need reform but a fundamental transformation. We need a transformation process. That is always difficult. Having worked all my life in the public system, I know that to shift the public system or the NGO system takes time; it takes a lot of effort. But I think if we put ourselves in the shoes of the consumers and carers they are clearly saying that the current system is not working for them and we need a different approach to mental health.

I will finish by saying that we support the directions that were set in the Mental Health Commission report, particularly, again, from a consumers and carer perspective. Let's have a system that focuses and is incentivised for outcomes, not for maintenance, whether it is the public system, the private system or the NGO system. We should have incentive payments based on outcomes, which means we are helping people move on with their lives rather than continuing to rely on the service delivery system. Thank you.

Senator WILLIAMS: Mr Meldrum, you obviously do a lot of work overseas in your organisation.

Mr Meldrum : Yes.

Senator WILLIAMS: What are they doing better overseas than we are doing in Australia? What have you learnt?

Mr Meldrum : In some areas—say, working in regions and gathering together all the funds that are going into mental health and cashing-out and capitation schemes and so on—there are some pretty exciting initiatives, in parts of Canada and parts of the UK. There is a real attempt to understand what is happening with all the dollars in an area. I think the evidence is that it works best if you can settle on the region, where everybody knows what is there, and try to get over the issues of Commonwealth and state boundaries. That is exciting stuff that I do not think has happened in Australia yet.

In terms of the National Disability Insurance Scheme, the evidence from a number of countries is that we need to be very careful that we do not end up with half a dozen huge for-profit providers in Australia rather than a lot of current organisations because the funding model drives efficiency so hard that only the big ones can do it. That has clearly happened in the United Kingdom. I do not think any country would say that it has solved the issue of the final remaining people who are so severely disabled and mentally ill—the last wave of people we de-institutionalised 20 years ago. I do not think any country would say that they have finished that process well. Most countries you read about still have large homeless populations, of whom about 70 per cent have severe mental illness. Most countries would still say that their jails are full of people with mental illness.

I was looking at the population of jails in Western Australia the other day, and 20 per cent of the women in Western Australian jails have schizophrenia. That is 40 times the community rate. Nearly half of them have had suicidal thoughts in the past month. There are huge numbers of mentally ill people in prisons. I do not think anybody internationally is doing way better than us on that last, most difficult-to-support group.

Mr Rosenberg : If I may add something to that, going back to the numbers I guess the question is, what problem are we trying to address when we are thinking about whether anybody is doing any differently? You can say that about 3.1 per cent of the population has severe and persistent mental illness of the kind for which they are likely to end up in a hospital.

Senator WILLIAMS: Here in Australia?

Mr Rosenberg : In Australia, yes. In 2010-11 the percentage of the population receiving state and territory hospital acute services was 1.6 per cent. Roughly half of the population are able to receive care, so we are already short, if you like, by that factor. But what is interesting is that in 2006-07 the number was the same. So, there has been no rate of change of access to public acute hospital services for people with severe and persistent mental illness. I raise that because—

Senator WILLIAMS: At the same time, a lot more money has been put into the whole—

Mr Rosenberg : Yes, well—over the same period we had 13 per cent fewer inpatient beds and 15 per cent fewer inpatient days but 20 per cent higher costs and a 50 increase in expenditure. I cannot explain that to you. I am an academic; I am supposed to be able to explain things. But I cannot explain that to you. Obviously there are higher wages and so on. I always say that putting new money into old systems or failed systems is a moribund approach.

But the reason I interjected—I am sorry, Senator—was just to say that one of the other contrasting places to look at would be New Zealand. I realise that they are a little bit foreign, but the change that was led by the New Zealand Mental Health Commission in the mid 1990s is worth thinking about. Their mental health commission responded to the views of the sector—psychiatrists and others—to basically say: 'Our system is unsustainable. The revolving door of access to care is spinning too quickly. We're seeing the same people without actually making a big difference to their quality of life. We need a different approach.' In New Zealand that really caused a change in the way they funded. I was here this morning and heard the testimony from the national commission, and they noted that the NGO sector in Australia, which provides psychosocial rehabilitation support, is about seven per cent of the total health budget. That is roughly one-quarter of the amount New Zealand spends on that kind of care.

The last thing I want to say is that I think we need to be careful about splitting things between clinical and non-clinical. We are finding now that a range of community based organisations, including ones like Aftercare and MIFA and so on, are now looking to augment decades of expertise in psychosocial rehabilitation and support with access now to clinical services—psychologist, psychiatrists, general practitioners, nurses and so on—to build new approaches. So, I am saying that New Zealand has chosen to change the pattern of their mental health investment, and it has caused an increase in access to mental health care. They have gone a long way further than we have to lift the rate of access to care, particularly for people who have persistent and severe mental illness.

Ms Rutledge : Coming from a slightly different angle, and from RichmondPRA's perspective—we work in a way that is very strongly led by people with a lived experience of a mental health issue, and we also support the National Mental Health Commission Review and the direction that it proposes—while there are many things that are wrong, I do not think it is fair to say that we do not know what works. We do know many of the things that work, and we have evaluative data about what works. Organisations like Aftercare and ourselves invest in action research—real research, with people who have a lived experience—and can point to significant outcomes for people who have a lived experience of a mental health issue—getting employment, getting long-term housing, staying well, staying out of hospital. So I do not think access to the public system is the best measure, because it is really about wellness and physical health and those sorts of outcomes for people. And we know there are many programs that work. I mentioned Partners in Recovery, and it is working. It is being formally evaluated by Urbis on behalf of the Department of Health, and there is real data that shows already that not only is there a very high level of satisfaction with the service people are receiving—that people feel that for the first time their lives have been supported and that they are receiving ongoing support and staying well and staying independent in the community—but also people are getting housing, they are getting the sort of support they need. That data is coming through from the Urbis research and is demonstrating that Partners in Recovery is reaching many of the people the Productivity Commission talked about and for whom the NDIS is a real way of funding their ongoing support. So again I say that it is really important that we look at the macro system—at the levers and the funding arrangements—and at how to get proper investment in the community setting. As Sebastian has said, the under-investment in community settings is really a major deficit in the Australian system. We do know what works and we have a lot of data about that.

Mr Frkovic : I have done a bit of work around comparing systems—Australia, New Zealand, the US, Italy, Trieste, the UK and I am going to Canada soon as well. No-one has the perfect or the right system; I have not seen it yet. There are some programs in some jurisdictions with some really interesting arrangements which are producing some phenomenal outcomes, but from a systems perspective—and there could be other people around the table who may know more than I do—from what I have seen there is no perfect system around mental health. But I have seen some phenomenal programs producing some phenomenal outcomes for people. I will pick up the point made by Sebastian and Pam. What we do not have right in this country, and the Mental Health Commission report picked this up, is that we do not have the right balance of investment.

I might not have the latest data, but New Zealand got to the stage where they had an investment in the community sector—I talk more broadly about the clinical and non-clinical in the community sector—at such a level that they started to feel the pressure come off their ED departments and their inpatient beds. That was with about 35 per cent of the mental health budget going into the community sector; that was the point where they started to feel it. That could be different for Australia and other jurisdictions, but you get to a point where, if you have supports for people in the community, you will see that translate into pressure on inpatient beds and ED departments. I cannot tell you what that percentage is, but I think it is a bit like New Zealand: we need to keep investing until we see the benefits.

Senator WILLIAMS: On that very issue, I live in rural New South Wales and I think we have a scattergun approach to mental health with money. Let me explain why. I see money go into Centacare, then Anglicare and then we have The Salvation Army contributing. Then we have money coming out of agriculture for mental health because of drought assistance and so on. How do we make it more effective? Ms Rutledge refers to unemployment, and I get very annoyed when we talk about unemployment in rural Australia. I will tell you why. You can go to any abattoir in Australia, and it is half full of foreign workers—the locals will not work there. Why won't they work there? Where I live there are 850 people employed in the abattoir—a heap of people from Brazil and the Philippines. The locals do not show up for work after a couple of days or they fail the grog test or they fail the drug test. There are jobs out there, but we bring in people from Samoa to pick our fruit. You do not need a college education to pick fruit; I did not need a college education to shear sheep. Is there a silver bullet solution to this—unemployment, the flow-on to mental health, the drugs? Ice is a huge worry, and it is out in the shearing sheds now; it is out in the small communities and in the big communities. There are drug busts in country towns where they are manufacturing drugs. We need a holistic approach to put all the pieces together to solve it.

Mr Quinlan : It is not a silver bullet, Senator—

Senator WILLIAMS: No, there is none. If there were, I wish you would bring it forward and we could fire it.

Mr Quinlan : but I could propose some ideas. All of those programs that you listed are purchased by government and each year, in 99.999 per cent of cases, government will sign off on those contracts at the end of each year and say, 'Thank you. You delivered us what we wanted you to.'

Senator WILLIAMS: Government or department?

Mr Quinlan : Department. We would suggest that what is missing from that system is any overarching goal. The national Mental Health Commission in its most recent report—

Senator WILLIAMS: Let me stop you there, if I could. We just heard from the previous witnesses that the problem starts about the abuse of children at three and four years old. That is a huge concern. How do we in government target bad parents who neglect and abuse their children? We cannot have federal police looking in the window of every house, saying 'You're doing it wrong. We're going to lock you up and take your kids from you.' I just shake my head and say, 'Why would anyone neglect or abuse a child?' That is the first question I would ask, as a father of three and a grandfather of three. Where do you start and where does it finish? This is a huge problem.

Mr Quinlan : It is a huge problem. If I can continue, what we fail to do is—

Senator WILLIAMS: Sorry for interrupting.

Mr Quinlan : No, you are welcome. What we continue to fail to do is to set any overarching targets. So we ask those organisations that you listed—we ask Centacare to look at some family services, we ask Anglicare to do some youth counselling and we ask the Salvos to help out with financial support. Nobody ever sets a goal for your area and says, 'Okay, in the area of Inverell, here is what we want to achieve with our families: greater stability, higher employment rates and so forth.' We do not go to that local community of Inverell and say, 'Okay, what are the local assets and resources in terms of the abattoir and the agencies that are working there? Overall, how do we actually target this problem? We will put all of the money into one pool.' At the moment, I can guarantee you that all of those agencies working in your electorate are drawing a pittance of funding from 20 different funding sources each to try to put together a comprehensive program. What I think the commission has done is say, 'We don't want to support a system anymore, we want to look at some outcomes.' They have listed some very solid outcomes that could be agreed in the mental health space, which is to say that we want people to be in more secure and stable housing, we want people to be in employment, we want people to be less engaged with the criminal justice system—

Senator WILLIAMS: You say you want people in employment, but what do you do with the people who will not work—those who have jobs offered to them but who will not show up and who refuse to work? It is great to say that you want people in work, but what do you do with the sector of the community who will not work and who refuse to work? I know they are out there.

Mr Quinlan : I think what you need is a program of job support that extends beyond being a simple job placement program.

Senator WILLIAMS: I think it comes back to the three- and four-year olds, and having a work ethic imbued in your children. That is where I think it stems.

Mr Quinlan : I am sure that is a contributor too. Nonetheless, we have unemployed people who have limited capacity to take up job opportunities.

Senator WILLIAMS: Generations. In one family, three generations that never worked.

Mr Rosenberg : Pam is correct in saying that we know a lot about what works, but that is program by program. So, we know whether this program is quite effective and we know, for example, if there is a program which would effectively deal with drug and alcohol issues as well as mental health. So, there are programs which we know have got some evidence to them. They fail to scale—so they might be available in the region next to you, but not at Inverell. Why is that? That is the way funding has rolled out and it is very unfair.

What I wanted to say was that we do not actually know about the global accountability or measures—if you like—of our success. For example, we do not know about the rate of housing amongst people with mental illness. We use some other data and try to cobble together a picture. It would be good to be able to know about the rate of unemployment for people with mental illness, but we do not know about that. It would be good to know about the rate of social participation by people with mental illness, but we do not know about that. It makes it very difficult for people who are well-intentioned decision makers and funders to be able to say, 'That's working.'

The other thing about the commission and what it was looking to do was to establish regional approaches to accountability so that, for example, in Inverell you would be able to say, 'What's another area that's like us—a similar sort of region with a similar number of centres and similar characteristics? Let's have a look at what they're doing and start to compare'—

Senator WILLIAMS: Dubbo abattoir. They are relying on foreign workers and backpackers to run the abattoir.

Mr Rosenberg : 'Is there is difference from what is happening in Dubbo?' So, if Dubbo has access to—I do not know—service X, a head space, a something-or-other. Is there some difference around the composition between different regions to try and get around the fact that—as I said in my opening statement—the experience of mental health care varies wildly depending on where you live. That is something that could be assisted by trying to put in place consistent outcomes and benchmarks for people to compare from place to place.

Senator WILLIAMS: With local accountabilities.

Mr Rosenberg : With local accountabilities.

Prof. Hopwood : You have highlighted some of the challenges we recognise every day, working in the area. They are, at times, sort of imponderable to calculate how they come about. But the thing we have under our control is how we organise our response. I would support the idea that, both at a regional level and a national-plan level, a national mental-health plan is an opportunity to say: 'What are the kinds of elements that we really need in a service response that are going to give us the best chance of solving these kinds of difficult problems?' Of course, there are going to be local variables within that. One of our challenges, at the minute, is that we need a diverse sector to meet the needs of the people we work with. But that can end up being confusing, difficult to approach and, at times, more competitive than is helpful. A national mental-health plan is a great opportunity for us to say a little bit more clearly how we want these elements to fit together, how we are going to govern that niche region and really tell if it is having the impact for the kinds of things you are talking about in the way we like. We really want to make the best of that opportunity.

Senator WILLIAMS: Mr Frkovic, was it you that mentioned Aboriginal mental health?

Mr Frkovic : Yes.

Senator WILLIAMS: You see, my attitude is that throwing money does not always solve the problem. I can take you back to the seventies when I was driving livestock transport in the Flinders Ranges and there were Aboriginal stockmen there—great stockmen, great blokes, good horsemen, good musterers, good drafters and good at their work. We threw money at them to solve the problem, and all we did was send them to the pub. They got on the alcohol abuse and drug abuse and everything else; there are probably very few working out there today. I learnt from that experience that throwing money to the problem does not always solve the problem. It has got to be spent.

Prof. Hopwood : I do not disagree.

Senator WILLIAMS: Efficiently targeted, as you say, to get the results. And not always money. But every time we have these hearings and everything, all we often get in submissions is more money. All my life we have put more money into everything but I do not think we have got any better results or a better society.

Mr Quinlan : With respect, Senator, I do not think any of the submissions presented so far have asked for more money.

Senator WILLIAMS: We are talking more money to the states for the hospitals et cetera from the federals.

Mr Quinlan : I would just encourage you; I think that the sector is—

Senator WILLIAMS: Mr Hopwood, you suggested more money to the states for hospitals et cetera in your submission.

Prof. Hopwood : I am not quite sure I did. I think what I said is we would be concerned about any reduction in hospital bed numbers currently.

Senator WILLIAMS: When I turn to Senator McLucas or the chair I will do some research.

Prof. Hopwood : I am happy to share that with you. I think Ms Rutledge has a little bit to add to that.

Ms Rutledge : Senator Williams, I absolutely hear your point about our need for community development and community-support interventions. We are needing to look at how issues arise in communities, from very young people right through to older people, especially in rural communities where there have been so many battering impacts on the wellbeing of those communities. I think we are in a position and we would very strongly say that we probably do not need more money. What we need is redistribution of the money—the overall funding that is in the system—long term.

I think that was the point the commission was trying to make in their original submission—unfortunately, it got misunderstood in the media around it—that there is an opportunity here to look at some different approaches. Taking the regional focus that the commission talked about and that we can see can work—working with the Primary Health Networks or some form of regional commissioning body—bringing all the organisations and the people in that community together, to work on community solutions for that community, is the only way to really build the sorts of outcomes that you are talking about. The mental-health sector is really well placed to work in that way—to work very broadly and holistically with housing and employment and local people, with Aboriginal communities, who understand how to build wellbeing in their community, and we can find new solutions with a redistributed way of working. We absolutely take your point about that being the outcome we are looking for.

Senator WILLIAMS: I think a lot comes back to parenting, and I think it starts at a very young age.

Mr Rosenberg : I think the commission pointed to several areas of existing spending where we could make efficiencies through reorganisation. I just pulled up the latest figures about the Better Access program, and last week there were probably just a tick under 150,000 services provided across Australia under the Better Access program, costing $15 million that week. So it is an enormous program and an enormous taxpayer investment of federal government money into this style of care. Only about 50 per cent of the treatment plans which are written by GPs are reviewed, and I would suggest therefore that the model of care is suspect. We also ask almost nothing about what we get for our money, for that expenditure. I guess my basic question is: are people getting any better? Having had their sessions of therapy with a psychologist, registered or clinical, do they get better? So we are making investments already which I think could be much better scrutinised. However, I would also say that, as is well-known, the burden of disease is about 13 per cent from mental illness, and the level of funding is in decline and is five per cent of the health budget. This is not taking into account other areas, but the burden of disease represented by mental illness is 13 per cent and the share of the health budget is five per cent and falling. I guess there is no particular reason that the funding should match the burden of disease, but I would say that surely that gap is telling. So I think we need to be very realistic when we know about the fact that only 13 per cent of young men who said they had a mental illness requiring assistance last year got any care for their illness, and 87 per cent of young men got no care for their illness. I do not think we can deal with that problem just through redistributing existing funding. There are huge service gaps which create enormous costs to the police and to domestic violence services and create a whole range of other community problems that have their root in untreated mental illness. I think we need to be very careful to distribute the money as efficiently as possible, but there is no doubt that mental health is chronically underfunded.

Senator WILLIAMS: Well, Professor Hopwood, your submission says:

… RANZCP submits that the Commonwealth Government must make an immediate capital investment to increase funding for mental health beds in state and territory public hospitals.

Prof. Hopwood : I am not quite sure which submission. Is this the previous submission from 2014?

Senator WILLIAMS: I am just reading this one here now. It is in our book work provided by the secretary.

Prof. Hopwood : If you read our recent—

Senator WILLIAMS: It is your submission from September 2014. It calls for immediate capital injection for funding for mental health beds in state and territory public hospitals. I just wanted to bring that to your attention.

Prof. Hopwood : In our recent response to the Mental Health Commission review—we heard that the Mental Health Commission were calling for a reduction in funding to beds—we indicated that a maintenance of the current level of beds would be desirable.

Senator WILLIAMS: I just want to make the point that in your submission you sought more money, because you were not sure of that. That's a win to me!

Prof. Hopwood : I was not present at the time. I accept that.

Mr Quinlan : Perhaps I could give you a suggestion as to how you might find some money to fund the sorts of activities that you are talking about in your electorate of Inverell. The National Mental Health Commission pointed out that most of our expenditure in the mental health space is not spent on the sorts of programs and services that we have been talking about. It is spent on the Disability Support Pension, and at the moment the government has changed the arrangements for the Disability Support Pension such that entry into that program is more difficult; entry into that program is controlled by independent doctors rather than people's own doctor. We could argue both ways about the merits of that, but, nonetheless, that is the policy. That policy is resulting in a slowing of entry into the Disability Support Pension such that in our estimate—and I would say it is very much a back-of-the-envelope estimate—somewhere between a quarter of a billion and half a billion dollars of savings will be yielded by the government for people who would otherwise have entered the DSP but will not.

Senator WILLIAMS: That is the problem when you have limited money. If we run out of money, like Greece, we will have none of these services in 20 years time—

Mr Quinlan : But what I am saying is there is a saving that is being made. I would suggest that is an opportunity for government to reinvest that saving into various initiatives in the mental health sector without increasing the overall budget.

Senator McLUCAS: Thank you very much, all of you, for coming along today. We have a lot of things to cover. I have five topics on my list here, so hopefully we will get to the end. Can I get your views about how the governance around the fifth national mental health plan should happen. The commission's very strong advice to everyone is that there is mental health and then there are all of these other things that are affecting people's mental health like their accommodation, their employment and their participation. What is your view about an idea that the fifth national mental health plan should in fact be a whole-of-government plan, not a health department plan, and potentially signed off by first ministers, which would then require engagement across all departments at both Commonwealth and state level?

Mr Quinlan : Mental Health Australia asked its members prior to the last COAG meeting to sign a letter to first ministers asking for precisely that. I cannot necessarily speak for all the colleagues at the table—they will speak for themselves—but more than 80 organisations across the sector signed that letter asking directly for that. The concern to us is that there are so many areas of action that are required that will involve, as we have already heard, housing, employment, family services and other programs, and such high-level funding arrangements and other arrangements between governments, that we think it is absolutely essential for those plans of governments to have not just the sign-off of first ministers but an actual commitment of first ministers. As Mr Rosenberg pointed out, the agreement between Prime Minister Howard and Premier Iemma at the time was critical. It is that sort of level of agreement that, I think, has seen us make the incremental breakthroughs that we have had along the way, and I really think we are at a point where we are unlikely to achieve the sort of substantive reform that we think is required without that sort of high-level agreement.

Mr Rosenberg : As was mentioned, there have been four plans already, and I think they have become decreasingly relevant. The last plan in particular was well written—it had all the nouns and verbs in the right spots and so on; I think it appropriately colonised the term 'recovery'—but it really did not have any money or any implementation or any real support for it to be actioned. Frankly, I would not support a replication of that process. I think it is a moribund process.

I would suggest that first ministers can direct attention beyond health, and that is clearly what is required, but what is mostly required, I maintain, is to fill the gap which exists between the GP and the hospital. That is why, rather than a fifth mental health plan, I would rather see first ministers sign off on a first national community mental health plan. In my mind, there would be appropriate links to primary care in that community mental health plan. You may well be asking at some stage, Senator, about the role of PHNs in fulfilling their role as part of community mental health. I would also like to see, within the community health plan, what the role of hospitals would be in arranging the appropriate discharge and other arrangements to smooth discharge for people back to the community through step-down arrangements, outreach nursing and a whole range of other things. I, for example, did not realise that Hospital in the Home began in mental health.

Senator McLUCAS: Neither did I.

Mr Rosenberg : It is a really good idea. I have used Hospital in the Home for other things, and you think, 'What a lovely thing to be at home and recover rather than in an institution.' We could return to those kinds of arrangements. So my money would be on a community mental health plan which had links to primary care and to acute care. The community part of it—and this is very important—would need to also figure very prominently in discussions around links to housing and employment services and community services and the range of psychosocial support services that are funded, currently, by Commonwealth and state governments. It would appropriately place emphasis exactly where I feel reform for mental health is most necessary.

Mr Meldrum : I strongly endorse what Frank was saying. The First National Mental Health Plan—and, amazingly, I have been around long enough to have been involved in it—had a little bit of bite because of its newness and, in fact, it came out of a fair bit of argument between people on which direction we should be heading. In that sense, it was quite influential.

With the last couple, in my view, you have been able to read them and say, 'That's about right,' but that is about the end of the conversation. There has been nobody made accountable to do something about those, particularly in the Commonwealth-state divide. You have mental-health plans in every state and territory being developed, as we speak. They either have just been released or are about to be released or are starting to be formulated. That is the situation at any given time. Most of them are the same. Most of them do not have any sort of a timetable or accountability for implementation. This one needs state ministers and the Commonwealth minister and key departmental heads not only to be saying, 'This looks like the way mental-health services ought to look' but also 'It contains some specific accountabilities for outcomes that will lead to some implementation.'

The First National Mental Health Plan, in fact, could have been a lot more influential if more people had done what Jeff Kennett did in Victoria. He took the First National Mental Health Plan—whenever he got into power; I think it was '92 or '93—and said, 'This needs an implementation plan.' They wrote a blueprint for what it would look like, to implement this in Victoria, and went ahead and did it. From the mid 1990s until quite recently Victoria had, by far and away, the best range of community mental-health services of anywhere in Australia. That is why. They put an implementation strategy into place. This one needs one.

Senator McLUCAS: The message from the commission, this morning, was very much around building-in an evaluation tool at the front end of anything. I suppose that is where you would start. I want to move from that issue, if that is okay, to the National Mental Health Service Planning Framework. Did any of your organisations have much to do with the development of that? I asked the commission this morning about whether they were given access to it and they advised me they were not. Do you have any comments about that and recommendations to this committee about what should be happening about it? I ask these questions at Senate estimates all the time and I get patted on the head, a bit gently, and am told 'It is all going along swimmingly, Senator.' I think we are getting to the pointy end of getting it out there.

Mr Quinlan : We have all been waiting, I think, for the National Mental Health Service Planning Framework to come out the other end. If I can provide a crude summary, it is fair to say that both the government and the sector invested a couple of years in working through a model for the provision of mental-health services and, as I understand it, some of the people at this table will have been involved in that process. What the process ought to do was say, based on the best evidence we have available: what are the sorts of profile of services you would expect to be available in the community, the sorts of services we might be expected to have available in the electorate of Inverell or anywhere else? Then it mapped that against the populations of people who might have particular illnesses. It also said that realistically we will, perhaps, never provide services to all of the people who have particular illnesses. It made discounts in its process for the fact that not all people will always get access.

We have seen parts of it. It is not yet available for release. It is fair to say that any of the people I have heard talking about it describe it as the best model we have for this sort of provision of care. It runs the risk of locking us into older models of services. It is more of a snapshot than a prediction of future. Nonetheless, it gives us an excellent model for working into the future. It is fair to say that those across the sector who invested a lot of time—and it is true to say that there were some hundreds of people across the sector—in developing that model have been somewhat frustrated by the fact that it has not yet managed to come out the other end of the process. This is because it is likely to give us some of the answers to the questions that David Meldrum alluded to—what are the numbers?—and gives us a platform where we can have a sensible debate about who is in what group and where the sorts of services for them should rest.

Senator McLUCAS: Mr Quinlan, you said a snapshot not a prediction. Does that go to the question of this being a current workforce funded by health rather than a look at a workforce funded by health and others? DSS spends a lot of money in mental-health services. Is that what you meant by that phrase?

Mr Quinlan : What I meant was it modelled particular forms of care. As I understand it, and others might correct me, it certainly focused on health but also extended well beyond that into the sorts of programs that might be available in the community. Any picture like that runs the risk of being a model for us doing what we have always done. I would want to argue that, yes, we need the mental-health service planning framework but we need a framework for ongoing planning of mental-health services. This is because we will innovate; we will learn. Regionalisation of services will teach us new things. What we need is that kind of process to go on marketing and remodelling services into the future.

It will be a helpful snapshot when it is available. It would be even more helpful to have a process where, for those with expertise in the sector, those looking at the best evidence available, those trialling new approaches, those evaluating emerging approaches—like Partners in Recovery and so forth—there is a process for us to engage and feed that into the ongoing development models.

Mr Rosenberg : I fully concur. That should be made public and used and analysed and further developed. What I want to mention with regard to the framework is not only that it would be good to have it revealed but also to go back to the point that Frank raised, at the very start, about the range of different things going on at once.

The framework really is about the best use of limited resources for the population. It is a population based approach, and most states and territories have used resource-allocation formulas of one sort or another. It would be good to make that clear and transparent, so you knew where the money was going and to make sure it was evidence based and so on. I would certainly look to include the community sector in that, as I believe the framework does.

On the other hand, there is also a policy stream that is very clearly pointing us towards individualised packages of care. I do not understand how those two things go together. We have to think about that. We have a very strong emphasis on fee-for-service in our current response, yet a lot of the innovation and so on is pointing to blended payments systems. I do not understand how those two things go together. I would also say there has been a lot of interest and investment in activity based funding as a way of being clearer accountability for the way budgets are put together and spent in mental health. At the moment, we are choosing some dumber historical block funded approach to funding. I do not see how that goes.

The commission talked about regionalisation but our approach to decision making is still largely centralised in the state capitals. There is a lot of talk around commissioning services, yet we still have competition between providers through tendering. There is a range of different policy conflicts embedded in our current approach, which are partly to do with the number of different issues we are dealing with but they do not make it easy.

Prof. Hopwood : The activity based funding has obviously been explored through the Independent Hospital Pricing Authority. The missing element, in that, remains outcome-driven funding. It is a different way of funding things, but it does not necessarily change the outcome. The status of that is at this moment unclear, but we would reserve—if it became more clear as an important consideration, well, that is great, so you fund it on what you do, but does it actually help anyone? It remains central to what I have said about a lot of things.

Senator McLUCAS: Professor, a health economist said to me once: if you build a bed, a doctor will put someone in it.

Prof. Hopwood : And there is no doubt, if we were to increase the number of beds tomorrow, people would fill them, but that is not necessarily the outcome we want. There is no doubt about that.

Just to follow up on something else Frank said: a really important element of any development in the mental health sphere is research to improve what we do. The risk that we continue to do what we do because we do it will be obviated if we measure the outcome better, but common sense says we would still like to improve on what we can do. So the very best we can do at the minute still could do with a lot of improvement. A significant commitment for research is an important factor—and that includes funding we currently receive from organisations like the NHMRC while a specific allocation from potential new funds like the medical research fund would be something we would like to support.

Senator McLUCAS: I think that is a nice little recommendation that we would be able to make.

Mr Rosenberg : It is worth noting that mental health is about as successful at getting NHMRC funding as it is at getting health funding.

Senator McLUCAS: We have covered the planning framework issues now, which leads me neatly into regionalisation and regional services. My next topic is NDIS, so I am not forgetting that—is that okay, Senator Williams; I am not being too greedy?

ACTING CHAIR: I think Senator Williams might still be doing a bit of research over there.

Senator WILLIAMS: No, all good.

Senator McLUCAS: Let us go to the question of regionalisation. There was a very strong recommendation from the commission to move to a regional approach in planning and service design and delivery for mental health services in the broad, but also around suicide prevention—so it is almost in two streams there. Can you talk to us about what your organisations think about those recommendations and what you think the primary and mental health networks might look like? That was one thing that Mr Quinlan forgot to put in his list of balls in the air at the moment. These organisations are one month and 25 days old, so what do we have to do? We are going to have a quite big shift in a short period of time. What do we have to put in place in the networks to make sure that we do what Commissioner Crowe said, 'If we're going to change something, we ought to change it for the better.' It has stuck in my head.

Mr Quinlan : We just had a meeting of our members again, if you do not mind me jumping in. Some 60 of our members had a meeting ahead of consultation with the Department of Health here about the response to the National Mental Health Commission's review and the ERG process, and Primary Health Networks were one of the topics of some heated and considered discussion. It is true to say that there is very broad agreement about the need for regionalisation of our approach, to look at whatever that means, but it is also true to say that there are some reservations, not necessarily terminal ones, about Primary Health Networks just because, as you have rightly pointed out, they are so new. The concern I would summarise as this: if Primary Health Networks are dominated by GP interests and a GP-centric approach in the local community—and this is not to suggest that they are—then that will achieve certain goals but it will not achieve the breadth of engagement that many of our members are keen to see.

If we are going to achieve the breadth of agreement and planning that we need, then we would have to go somewhere to what the commission recommends, which is primary and mental health networks. What would that mean? That would mean that community organisations, consumers and people with a lived experience of mental illness themselves and others were all engaged in those governance structures, on the boards of Primary Health Networks. I think it would also likely mean that Primary Health Networks would also look at their localisation and many of them, I suspect, would say: 'Actually, we're not that local. If there's only one Primary Health Network in this vast area, perhaps we need to have some structures by which we can have sublocalisation, if you like.' So I think there is a lot of anxiety about us investing too much too early in structures that are just emerging, notwithstanding, I think, the broad agreement that we need local structures to steer and govern investment.

Prof. Hopwood : Yes. It was a very useful discussion at Mental Health Australia, and I support those comments. I think that, while we can have discussions in relation to the Primary Health Networks, we need to acknowledge that some of the same issues apply to the governance and administration of the acute health networks that, within the mental health space, control both acute hospital beds and some of the clinical public community services. They too are charged with health care for a region but filtered through the lens of what runs a hospital—the budget and so on and those concerns. We are at the same risk of replicating the same issue with the Primary Health Networks. So there should be cross-governance arrangements such that they share responsibility. They are meant to be looking after the same community, or close to it, usually—with some of them it is not quite. Therefore they should be looking for the same outcomes, but the current governance arrangements and funding streams do not support that; in fact, they tend to—perhaps inadvertently—occasionally produce the opposite outcome, with unhealthy competition for more resources to produce the same outcome with, therefore, inefficiency.

Mr Rosenberg : Here are my two bobs worth about this. I am a 'form follows function' kind of guy, and I would love to have the discussion about what sorts of services you are talking about. I must say I was on the edge of my seat as Allan Fels was talking about stepped care. I think one of the issues that are unresolved is: what is stepped care? What does it look like? What are those different steps? I think we need to be quite clear that at the moment I cannot help but suggest that the system seems to be run for the benefit of the providers, largely—and I would probably discount the community sector from that, because they do not seem to be benefiting much at all. Certainly I think any new system of stepped care is going to change and challenge current ways of working for health professionals and other service providers. And what does that look like? I think we need a very strong emphasis on psychosocial rehabilitation and support, community and living skills, employment and housing support. These are the kinds of things that Pam's, Ivan's and David's group are experts in, with decades of expertise and expert staff who know what works. Allan Fels has talked about step-up step-down services, but they are carefully put together to provide short-term accommodation for people. They are not wards for overflow from acute hospitals; they are a separate service and, I should say, have not been costed as part of activity based funding at the moment, so that is a gap we may wish to return to at some stage.

What we also need is multidisciplinary community mental health teams on the high street, and that would include a crisis capacity. Again, it will not stun senators to know that those sorts of systems, which engage psychologists, psychiatrists and others, were throughout Australia about 15 or 20 years ago and have been thoroughly dismantled since then. Services have withdrawn to the hospital and fee-for-service providers to their own practising rooms and out of the high street.

Senator McLUCAS: Can I just interrupt at that point. Is that because states and territories have reduced investment?

Mr Rosenberg : Yes, there is no doubt of that.

Senator McLUCAS: Is it basically states and territories—the old community health centres that we knew in the olden days?

Mr Rosenberg : As I say, nobody owns community mental health, and I think there has been a withdrawal by the states and territories to the areas they know they control, which are hospital based services. That is why you have some real confusion: when they talk about community based services, they include hospital outpatients, who are by far the largest component of their supposed community spending.

Mr Quinlan : I think the current funding discussions around the NDIS risk exacerbating the point that my colleague is making, because the fear is that there is going to be nothing left in the pool to fund the sorts of services that Sebastian is talking about.

Ms Rutledge : Can I just put in, in parentheses, that I think that that diminution of services is also an outcome of some unanticipated consequences of federal-state funding arrangements. As you said, nobody owns and supports community mental health, and it fell between the cracks of the Commonwealth and the states.

Mr Rosenberg : With respect to mental health community outreach nurses, the Mental Health Nurse Incentive Program is a proven program that adds so much to the armaments of GP practices so that they can follow people into the community and provide care. The cost is only $40 million, which would be less than three weeks worth of the Better Access program. It is a tiny program with massive effectiveness. So, again, Australia has a program which it could scale but has not.

Senator McLUCAS: Is that because we do not have the personnel?

Mr Rosenberg : That is part of the issue and, again, the amount of money that is set aside for workforce development is tiny. Some of our colleagues in the College of Mental Health Nurses have been struggling to build that workforce.

Prof. Hopwood : The Mental Health Nurse Incentive Program is capped, and that limits—I think there is adequate workforce to expand it further and distribute it more evenly. But it is capped.

Senator McLUCAS: I did not know that AMSs are not allowed to have Aboriginal mental health workers.

Mr Quinlan : The Mental Health Nurse Incentive Program is one of those programs on the list that has been extended on a 12-month-by-12-month basis for quite a number of years. It is not unique to this area, but it is one of those areas where clearly if you are a nurse in the community who is thinking, 'Where will I build my career in nursing?' this notion of 12-month-by-12-month funding does not create—

Mr Peters : It is common across a lot of the services.

Mr Quinlan : It does not create a platform for people to say, 'That's where I'm going to invest my future', because you never know—

Mr Peters : The uncertainty of mental health funding is probably causing as much stress as anything else, no matter what it is—if that makes sense.

Mr Rosenberg : The Mental Health Nurse Incentive Program would also assist greatly with managing the physical health needs of people with mental illness in primary care. Senator Williams asked about other places—

Mr Meldrum : I just want to make a comment about Primary Health Networks before we finish on that topic. The notion of mental health planning and strategy and commissioning and so on, and all the money being thrown into them, as Frank said, was controversial. But ultimately, in terms of the final outcome, we can all see that they are the only game in town for a regional structure and that we are going to have to work out a way to do it. I also feel they need a personality transplant in a lot of cases before they can do it, because they are focused specifically on the role of the GP, who has an important role but not all the roles. The key issue is that they do not have a mission. It is going back to the stuff that Seb particularly was talking about. Why suddenly chuck a whole amount of money at an organisation yet again without specifying what we want it to achieve? And while we have a national mental health plan that has not been finished, while any implementation strategy is yet to be dreamt up, while the NDIS arrangement is so unclear et cetera and while we do not have any of those key outcome objectives, there is no mission to give them. I would suggest that we are at least a year away from being able to describe to a Primary Health Network, 'The mission we need to achieve in mental health with this money is this.' That would be the very first step before they get given the job, from my perspective.

Senator McLUCAS: That is a very clear recommendation, I think. I am seeing nodding from other people around the table. It will take 12 months before we can actually start doing something around that.

Ms Rutledge : I just want to reinforce the point Frank made about the governance structures, because the Primary Health Networks really are Medicare Locals reinvented. It is the same people and some of the same attitudes and some of the same values, and I think we really need to think about how we get a stronger mental health presence into the governance of those organisations as well as a stronger sense of the outcomes we are looking for.

Senator McLUCAS: I wonder whether I could ask you to take some homework away on that question, and perhaps you have some specific advice for our committee about what we should do in that next 12 months to ensure that the PHNs or the PMHNs or whatever we are going to call them are transformed to the point where they will really be able to capture the responsibility of primary and mental health care at the same time.

ACTING CHAIR: Is that essentially a question on notice for the whole—

Senator McLUCAS: It is a QON for everybody. You were finishing something off—

Mr Rosenberg : I still have a long list here—a Castro-style monologue! I will just keep going. One of the things Senator Williams asked about in terms of differences to other places was the use of peers. One of the only targets that were set in the fourth national mental health plan was a target of one per cent of the total workforce to be peer workers. It is pathetic. These are proven, efficient ways of delivering support in the community to people with mental illness and again characteristics of community mental health service should have a large role for peers. Again I would be asking Primary Health Networks: 'To what extent do you offer a peer workforce, a nurse outreach workforce?' These are all components of part of a stepped care arrangement. Personal Helpers and Mentors and Partners in Recovery are precious, scarce resources in this area.

Senator McLUCAS: Given you said Partners in Recovery and PHaMs, can we move then to the NDIS and pick up on Mr Meldrum's point? You said that you expect 70 to 80 per cent will not qualify to get a tier 3 package under the NDIS. That is for PHaMs. Why do you say that, Mr Meldrum?

Mr Meldrum : Partly because we know PHaMs well. Just in my organisation, apart from after-care, between us we have something like 40 to 45 PHaMs programs across the country, so we know that population very well. When you look at the definition of severe and persistent mental illness and complex psychosocial disabilities we can clearly see about 20 per cent of them fit that characteristic. That was the way that program was designed. It was not designed to be totally that very challenging group; it was designed to be a wider cohort. So in a sense we are saying it should not be more than 20 per cent of them fitting. That is the way the two programs have been designed. It is a highly contested space. A lot of people in the National Disability Insurance Agency say, 'No, we are enrolling up to 80 per cent of people from some PHaMs programs.' I am yet to see the proof of that but if they were I would be alarmed because that is dramatic mission creep. They should not be going out to people who are coping well most of the time and giving them small packages of care. That is not what the NDIS is about.

All I can say is that we keep on looking at our PHaMs programs and keep on seeing the same results. I am very up to date with what is happening in the Hunter, which is the most advanced area in terms of transition. I was talking to people there only last week and they said it is something like 25 per cent at the moment of people in PHaMs programs are being found eligible, so we know we are in the ballpark.

ACTING CHAIR: Mr Frkovic, do you want to talk about PHaMs?

Mr Frkovic : We need to remember that PHaMs was designed for people with severe, persistent mental illness but the people we are seeing at the moment are people who might need a very small amount of support, even though they have a severe persistent mental illness. They have a whole range of other supports. We provide a little bit of support and they maintain good quality of life in the community. It is that that will be missing. They will not qualify for a NDIS tier 3 package but they will also lose that little bit of support that they currently rely on to be able to live in the community.

PIR is slightly different even though there are elements of that, because we are trying to pick up the group that is falling through the service gaps. We suspect with the PIR group more of those will actually qualify for the NDIS, but PHaMs is the safety net. Potentially we could lose that safety net. We keep hearing about ILC and that the tier 2 level will provide coordination to this and that, but coordination to what when that whole tier 2 level of support will disappear?

Ms Rutledge : As I am sure you are aware, there is a major national systemic issue around the NDIS which is to do with where the money is coming from in each state and territory, so we are experiencing some unanticipated consequences of the fact that in New South Wales the money was historically disability service money, in Victoria it was historically mental health money and it is different in every state. It is part of the bilateral agreements. This puts the National Disability Insurance Agency in a very difficult position in trying to create a national framework of eligibility and support until we can get some greater clarity around that broader issue. The NDIS is intended to fund disability supports for people, including people with a psychosocial disability, but it grew out of the broader disability sector. There is a lack of definition about what is a disability support for a person with a mental health issue compared to what has traditionally been a health support for those people. That is the piece of work that many of us are trying to get engagement with. The agency understands the need for that piece of work to happen, but I think it is sort of clouding and confusing the whole framework about what it is that the NDIS will provide and fund for people with a long-term severe and persistent psychosocial disability and what will remain as a Health funded support. That is where I think we start to get into this confusion about: where will support for all the people who do not get tier 3 packages sit? We do see that the Partners in Recovery model is really well positioned to be reframed to go on being funded as part of the solution, not only for supporting the tier 3 packages but also for trying to fund the level 2 and provide some block funding for ongoing support for people who do not get their tier 3 packages, but it is a very big, clouded picture at the moment, and there is a need for some really detailed and committed work. Many people are involved in it, but it is really hard to see how we are going to get traction in that space. I think the next year is really crucial about getting that traction.

Mr Quinlan : We have made some recommendations around precisely that point. I want to be absolutely clear, because we are often misheard. Mental Health Australia are not making a case for more people to be included in the NDIS. We remain largely agnostic about who delivers the services to the people in need. Some of them will come from the NDIS. Some of them will come from existing or ongoing Commonwealth programs and some of them will come from state government programs. Largely, we are happy for state and federal governments to sort that out amongst themselves. But I think there ought to be mechanisms available—and I could provide you with some more details about this. If Sebastian, who is on the PHaMs program at the moment, comes into my NDIA tomorrow for assessment and is refused—I say, 'Sorry, Sebastian; you can't have the NDIS service and, by the way, your PHaMs service has been enrolled'—he walks out the door entitled, under the current agreement between state and federal governments, to a continuity of service, a guarantee of service. Governments have agreed that Sebastian is entitled, but Sebastian walks out the door with no mechanism to tie him to that guarantee. A very simple process, in my view, would be for the NDIA not to say, 'Good luck, Sebastian; you're on your way,' but to say, 'Here is the state or the Commonwealth program to which you are now entitled.' That would be a very simple mechanism to turn that guarantee of service, which governments have happily committed to, into some sort of concrete action on the ground, because otherwise I fear there are going to be a lot of people falling through the cracks.

Mr Rosenberg : This is another one of those strange conflict policy areas that I was alluding to before. You have now got national recovery standards which are really about trying to encourage and arrange for people to move through a system of care with a view to them getting better, which of course most people with mental illness do. That is the goal. However, the way we fund services often runs counter to that, and I think this comes out of the NDIS and it comes out of other arrangements with our current funding to the NGO sector, in particular, where their funding is dependent on me coming back next Wednesday still being sick. Again, you have just got a conflict here between what we are trying to pursue as an outcome, which is people's recovery, so they can go back to work and resume their lives, have fewer days out of role, as they say, and what we subject service providers to in terms of the way they are funded. Again, this is a policy conflict which makes things very unclear.

Senator McLUCAS: We should pay you if your patient does not turn up!

Mr Rosenberg : It's a deal!

Prof. Hopwood : In trying to link together consequences for various parts of the systems, perhaps this is a somewhat surprising figure. Between 2007-08 and 2011-12, the Institute of Health and Welfare figures show the average length of stay in a public psychiatric hospital went up from 48 days to 69 days, which is very counterintuitive.

Senator McLUCAS: What years were those?

Prof. Hopwood : Between 2007-08 and 2011-12. It has subsequently plateaued. That is counterintuitive, because we all know the pressure on those systems. The corollary is that many hospital directors say, 'I have a number of patients in my inpatient unit at any point in time who I do not think need to be here.' What does that really mean? They are usually talking about people with enduring disability; they are not well. They have enduring disability, but issues around housing and disability support mean that maintaining them outside of hospital, which everyone would desire, is not possible.

Senator McLUCAS: So medication is stabilised but they are still not well?

Prof. Hopwood : We have done as much as we can, if you like; I think that is probably really what we are saying. In terms of the efficient use of that resource, that is a problem, but it is also a very important group of people. One of the issues that we are seeing with NDIA work in other areas of disability is that those people who are currently in a spot, as it were, within the system can sometimes get missed—particularly if they are, for example, a younger person with brain injury in a nursing home. So I promote that as evidence of a need but also of a group that are very important to consider.

Prof. Hopwood : An unpublished national survey of beds carried out by acute ward bed managers in four states—not New South Wales—in 2006 suggested that the number of beds occupied by people who would be better off elsewhere was 43 per cent.

Senator McLUCAS: Has that changed in any way since 2006?

Mr Rosenberg : I do not know; it has not been repeated. I would imagine it would have gotten worse.

Mr Frkovic : I was part of that process when I was in government. Yes, the first survey results were even higher—I think they were just in the 50s; the second repeat survey results were in the 40s—people did not need to be in that bed for clinical reasons, picking up your point. They were stable but the major barrier for them to be discharged and placed in the community was around accommodation. Both clinical and non clinical support in the community was the major issue. We are talking about anywhere between 40 and 50 per cent of the beds.

Senator McLUCAS: What level of government should be responsible for the accommodation for the stepped down care?

Prof. Hopwood : It is a great question, because the solutions are diverse. It is important to acknowledge that, whilst they do not need to be there as in probably the acute hospital is not going to change things, some of them are highly disabled. So some of them are going to need quite specialised accommodation options—in fact, most of them. If it was easy, they would not still be there. Together with that, they are going to need high-level clinical and non-clinical support. Part of the complexity currently is that each of those three things—accommodation, clinical support and non-clinical support—comes from different spots.

Senator McLUCAS: I always say that there were no women involved in Federation.

Mr Peters : If I may say, one of the problems with mental health funding is the confusion about the funding and where it is coming from and then the competition for the funding. So you can see by the number of people that are represented—and the number of parties that are involved in mental health funding and trying to create a better outcome for everyone—that it is no wonder that the general public and those who need the care are confused and struggling. Those who are involved in it and leading it are also confused and struggling. Perhaps, to some degree, with all due respect, governments are confused and struggling.

Ms Rutledge : I sound like Pollyanna, but we, again, do know what works. We have some real living examples on the ground of 24/7 supported accommodation in the community for people who have been long-term in hospitals—HASI and HASI Plus. At the moment, those have been state government funded. We had one brief shining moment where there was the national partnership agreement, under COAG, for mental health reform where we did have Commonwealth state funding going to priority programs jointly funded and jointly agreeing on the outcomes. HASI Plus is one of those in New South Wales, providing 24/7 intensive support with good clinical backup—again, three or four pilots across the state with great potential to scale it up.

Mr Rosenberg : I do not think that we should limit ourselves to rethinking or reimagining the system outside of hospital and saying, 'Hospital is hospital, and it will remain so forever.' Again, parts of the reforms in New Zealand are to create hospitals in the community, where it is possible to go for acute care. In other words, these people are—I believe the term is—floridly unwell, and they go to a house in the community where they are provided with care which is led by consumers. Clinical and non-clinical support is provided. The psychiatrist comes to the patient rather than the patient going to the physiatrist. The person does not have to go a traumatic in-patient unit with guards; they have their own room in a nice house in suburban Auckland, and that is acute care and it is cheap. So I think that we need to reimagine mental health at a variety of different levels.

Ms Rutledge : We are running a very similar program in Hervey Bay in Queensland—a peer operated service where we have a house where the clinicians visit and people come and live. It is run by people with a lived experience of mental health issues. For everything that we know we need, we have living examples; it is about how we put them together into the package, scale them up and identify the funding framework. I think it really has to be that—as I think the commission said—the Commonwealth should step back from directly funding services on the ground in this sector. It should put some money in; the money needs to be there, but it needs to be channelled in a way that does not create a Commonwealth state divide on the ground, as we have seen to our peril. I think PhaMs has been a good example of that.

Senator McLUCAS: I have one more topic that I do not want to miss. I am a bit embarrassed about this. It is Indigenous mental health, and it probably should have been at the top of the list. Could we talk more about the recommendations from the commission around Indigenous mental health, what your views of those recommendations were and any recommendations that you would make to this committee about those recommendations?

Prof. Hopwood : I can talk to a couple of specific things. Certainly, in terms of the commission's highlighting of the issues around Indigenous mental health, we support them wholeheartedly. I do not see how you could possibly not. That is not the challenging bit; it is what to do. Specifically within the profession of psychiatry, we have focused on how we improve access and fit of workforce. New Zealand has reached parity now with medical school intakes of Maori descent compared to population. We have not. We are still about 50 per cent of the way there. If you look at medical specialists, we are considerably lower. We have been able to utilise some of the expanded training setting money that Andrew mentioned recently to encourage, specifically, Indigenous medical students to consider psychiatry, based on the committee that we have of Indigenous community members highlighting that that is what they want. We have had some success. We now identify medical students who are of an Aboriginal and Torres Strait Islander background who are interested in psychiatry. We promote them. That is the workforce that the community tells us that they want.

What will then attract them to go to where the communities are and keep them there is a set of different issues that are not unique to psychiatry, I have to say. Training an appropriate and useful workforce is clearly central, in our view, as one part of the solution. Working in those areas with an inappropriate workforce is perhaps—as Senator Williams previously suggested—not very effective expenditure.

Mr Quinlan : I was going 'hear, hear,' which I think is the parliamentary tradition on those things. Hear, hear.

Senator McLUCAS: Are you after my job, Mr Quinlan!

Mr Peters : The challenge should never be understated. I think that the air gets sucked out of it from time to time. It is certainly pleasing that you raised it, because I think it is still critical. It is still in every discussion we have. We were in the Northern Territory on the weekend. Amongst a number of other topical items you could imagine, of course it comes up. We support anything that helps that and supports the funding. Training themselves is interesting. That is something they really want to embrace. I probably jump to that STP area, because that is key to this. Where we can get funding to help support Indigenous mental health training, we see that as a priority of ours—certainly, as a college.

Mr Quinlan : Recently I was fortunate enough to be part of the Garma festival in east Arnhem Land. I think it is fair to say that many of the people I encountered there were baffled that our policies around these issues change as frequently as they do. I would agree with what Malcolm and Andrew have said about workforce being one of the absolutely central issues not just across psychiatry but across all of the disciplines involved in mental health. Having an Indigenous workforce working in those populations is absolutely essential. Professor Pat Dudgeon and Professor Tom Calma have produced strategies through the NSFATSIPMHSEW—or something like that; it is an enormously long acronym—the Indigenous social and emotional wellbeing framework. We need to give some of these frameworks the opportunity to have an impact. Rather than changing our direction mid-flight, there is what I think the doctors would call a dose response. You need to make sure that there is an adequate dose given. It is not just that the program fails. If the program is not delivered often enough and for long enough then it is not going to have a response. I think giving things like the social and emotional wellbeing framework a long enough life and future so that they can actually bed down and engage and start to yield results would be a key recommendation.

Mr Rosenberg : I used to do some work in the Cairns area with their local Aboriginal mental health service, and that was one of the first times where I came across PIR in a very effective way. There was an Aboriginal workforce that was working within that program, and I was blown away. But one of the things that they found very difficult was that the rules preclude PIR from working with kids under 16. It is a classic example of a well-intentioned program that is applied to mainstream health services with rules and so on, but its application to the Aboriginal community was so completely wrong and counter to their whole view about family and about the social and emotional wellbeing of the whole family. I think it was an example of the fact that we have got some things in place, but they need to be tailored appropriately to make the most of those opportunities.

Mr Quinlan : I think supporting the sort of community controlled organisations that are genuinely taking control of their own destiny and delivering programs is important. As part of my trip north I visited the Miwatj health service, where there is a genuine ownership of the local strategies and services that are being delivered in that community. I think those sorts of programs provide an excellent model for what we could be doing in other places too.

Senator McLUCAS: Mr Meldrum, Ms Rutledge and Mr Frkovic, of the services that you are running in PHaMs and PIR, do you have enough Aboriginal and Torres Strait Islander clients to reflect the population that you are serving? Are people enrolling in PIR and PHaMS at the appropriate level?

Ms Rutledge : The preliminary results of the Urbis evaluation of Partners in Recovery nationally are showing that it is reaching a much higher proportion of Aboriginal people than is in the population, so it is touching that central issue about lack of engagement, and the use of the support facilitation model is really enabling people to engage very directly and immediately with people with a mental health issue who may not have been able to engage previously. It is really showing its effect of reaching Aboriginal people. Certainly in the programs that we run that are not PIR, and we run a number of Aboriginal HASI programs, we are working very actively with the Aboriginal community—for example, in Western Sydney with the Aboriginal community controlled service—and I want to reinforce Frank's point about the government: we need to really recommit to Aboriginal community controlled organisations as a way of building community and building wellbeing from the ground up.

Senator McLUCAS: Did you want to add anything, Mr Meldrum?

Mr Meldrum : The PHaMS service is about on par with the percentage of the population. It is highly individualised. It is a service where people go to your home. It seems to work pretty well. I think I have seen figures on respite care services that suggest that does not work as well, that it has rather a group element to it. So the purpose-built ones for Indigenous communities have emerged there and have worked pretty well. My comment on that would be you cannot go any other way but to build and Indigenous workforce for the program. It is slow and difficult.

I have seen a couple of situations in the last couple of years with the federal government has been pushing to set up a service up in the APY lands or Thursday Island, or wherever, and to get on with it: 'We want it on the ground with clients in the next six months.' Our service providers had said that you cannot do it. We are not prepared to say that this program is under way until we have at least half the workforce from the local community and that will take us time.

Mr Frkovic : I can certainly vouch for that. We have taken an interesting strategy both in employing Indigenous people and workforce issues, as people talked about, building of the Indigenous workforce within our organisation across the various programs and investing quite a lot in terms of professional development, orientation and training. We have also offered services in many of the locations like Thursday Island, as you just mentioned, and in the cape, plus in South-East Queensland and in a whole range of areas. We have also looked at where we can add value to local Indigenous services rather than coming in over the top, building some of that capacity and sharing some of that. In fact, in South-West Queensland we took on a DSS contract where part of our agreement was that we would do the PHaMs—it is all Indigenous staff—with the plan to transition after three years to the local primary healthcare organisation, which is an Indigenous organisation. We tried a range of things to do that. I would say that in some of those locations are Indigenous numbers in most of those programs are quite high. There are different ways to do this but again rather than imposing some of the things, like the program guidelines, we should exclude some of these things. For example, I have to be careful what I say in public—we stretched the guidelines to suit the local communities, to be able, with the PHAMs, to have a lot more group interaction, social interaction, rather than the one-to-one model that we use predominantly. You have to make it fit the local community.

Senator McLUCAS: It is really good to have that on the record.

ACTING CHAIR: Time is against us.

Mr Rosenberg : Can I say one last thing. I feel very strongly that, whatever do next, based on one of the most important elements of the national commission's review, is to finally stop the situation where we really do not know the merits of what we are doing and whether we are making a difference to people's lives. What I would suggest and advocate for very strongly, is that instead of the current situation where we have thousands of databases and thousands of indicators which tell us about the numbers of beds, the number of days and whether the person that blue or hair blonde, whatever it is, we need a very limited, rational, practical set of indicators which would provide genuine accountability for mental health region by region, so that we can track whether what we are doing is making a lick of difference to people's lives. Part of that would also be to provide information for service providers to improve the quality of the care they provide. Neither of those systems is in place at the moment.

Senator McLUCAS: Would that be based on consumer satisfaction?

Mr Rosenberg : There is no validated collection of the experience of care for consumers and carers in Australia. It would be one of the key markers which would permit people to know whether the service they provided for that person helped.

Senator McLUCAS: Can I say thank you. That has been a fantastic session and as Australians we can be very proud of the commitment and passion you guys have for the work you do. I love working in this space. Disability people say, 'Don't do say "inspiring"', but I am about to. You do great work, thank you.

ACTING CHAIR: I have to agree, thank you very much.

Proceedings suspended from 12 : 54 to 13 : 40