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

ADAMS, Ms Tracy Joy, Chief Executive Officer, BoysTown

BEWERT, Mr Peter, Executive Manager Care Services, The Salvation Army Aged Care Plus

DALGLEISH, Mr John Roland, Manager, Strategy and Research, BoysTown

HAND, Mrs Narelle Marie, Program Manager, Anglicare

HEATH, Mr Jack, Chief Executive Officer, SANE Australia

JOHN, Mr Christopher, Chief Executive Officer, United Synergies

KING, Ms Susan Elizabeth, Director, Advocacy and Research, Anglicare Sydney

KYRIOS, Professor Mike, President, Australian Psychological Society

LITTLEFIELD, Professor Lyn, Executive Director, Australian Psychological Society

PHILLIPS, Mrs Karen, Manager, National Standby Response Service, United Synergies

PROUDFOOT, Associate Professor Judith, Head of eHealth, Black Dog Institute

ROSENTHAL, Mrs Nicola, Business Development Manager, The Salvation Army Aged Care Plus

ACTING CHAIR: I now welcome everyone to our second roundtable of mental health peak bodies and service providers. Thank you all for making the time to talk to us today. I invite you all to make a brief opening statement, and then the committee will ask questions.

Mr Bewert : Good afternoon, Senators, ladies and gentlemen. The Salvation Army Aged Care Plus is a dynamic provider of social and community services to the Australian people. There are numerous programs focusing on health, wellbeing, mental health, drug and alcohol recovery, and aged-care services which interface with the broader health system. Today we are representing the Salvation Army Aged Care Plus, which operates aged-care residential and community services on the Australian eastern seaboard.

The work of the Salvation Army has shown that many people with mental health difficulties face compounding disadvantage, particularly Aboriginal and Torres Strait Islander people; people living in rural and remote regions; those who are marginalised due to their sexuality, gender, cultural background or job; and people who have difficulties with alcohol or other drugs. People with mental health problems struggle to find acceptance and experience marginalisation. The symptoms of mental health problems can lead to isolation and a lack of sense of belonging.

If placement in an aged-care centre is required, these key elements continue and are often intensified. The reasons for this include lack of residential care places that cater for the specific needs of this client group. People with mental health problems, in our experience, generally do not have access to family members or friends, which can result in extremely high emotional needs once they are in a residential care environment. There is generally a reluctance of the aged-care sector to admit people with mental problems into mainstream residential aged-care services, due to the negative stereotypes that are often associated with that—specifically, behaviour associated with mental health problems, drug and alcohol use, personal hygiene issues and a history of homelessness. Low-care facilities catering for the mentally ill can have up to 90 per cent of residents who have been homeless. Many of these will be assessed as having high and complex needs. The funding tool used by residential aged-care facilities, commonly known as the ACFI or the Aged Care Funding Instrument, does not reflect the level of care and funding required by homeless residents assessed as having high and complex care needs, even at its highest levels, when we specifically look at mental health.

Challenging behaviours in residential care are increasing. Whilst these are usually associated with dementia, older people with long-term mental illness present with behaviours not associated with cognitive decline. One of the things we regularly experience is the difficulty with managing people who have multiple diagnoses. Particularly, those with a diagnosis of dementia and a mental health problem are often neglected with our health system as it currently stands, in that everything is bunched into the dementia diagnosis and often the mental health concerns are ignored.

Many placements fail for older people with mental health problems. The recognition of the need for a sense of place led to the development of some very specific models of care within the Salvation Army Aged Care Plus. My colleague Nicola is going to talk about some of our specialist centres.

Mrs Rosenthal : At Aged Care Plus we offer two specialist residential aged care centres which look after people with specific mental health problems. One is in Balmain. The Montrose men's home is a specialist home for men, the majority of whom—76 per cent, I think, as of today—have a mental illness, a long history of incarceration or institutionalisation, substance abuse and previous failed placements. Our Carpenter Court Aged Care Plus Centre is in Newcastle and up to 98 per cent of our residents up there have long-term mental ill health. As Peter said, the need to find a sense of place led to the development of our person centred behaviour support plan, which was recognised in 2014 with a Better Practice Award by the Aged Care Quality Agency and a Mental Health Services Award in 2015. These homes are specialist in nature and we have further offerings in our aged care portfolio which specialise to a lesser extent in mental health.

We have identified that for the management of older Australians in this environment there need to be specialist resources and living environments available which cannot be accommodated in generalist aged care services. One of those issues is around staffing. The staff in general aged care services have no mental health training, so the person is not able to be managed, they become disconnected from that community and the residential placement fails. We have made a deliberate attempt to specialise in these areas and we have really strong links within the communities to do that.

Further, within our service offering we operate three rural centres in New South Wales and one in Queensland. We will commence the building of a new residential aged care centre in the far north of Queensland in 2016. These issues around mental health and aged care are intensified in those rural areas. Consultation with staff has proven the ongoing challenges regarding access to appropriate and timely mental health services for residents, particularly where this acute. Despite staff accessing the best training we can find, there are times when more highly skilled professional intervention is required. Those challenges can be caused by a lack of local services and mental health professionals—specialist or generalist—support services which are too far away and too expensive to access and the stoic approach of people not seeking help in a timely manner or not wanting to have a stigma attached to them.

The challenge of life in a small community can impact on care. We know that GPs are reluctant to seek hospital care for people who need a mental health admission, particularly where the local multipurpose service cannot cope with that. We also have problems with GPs discharging patients with mental ill health from their books despite their long history of mental health problems. That is particularly pertinent when a GP is the only GP in a town or when they are overwhelmed with people and they need to get some people off their books. The problem then becomes that we need to wait to get the person back onto the GP books when something happens, and that can be very challenging.

We are very passionate about providing care to the marginalised and the vulnerable. This is in our DNA as the Salvation Army and our history. We will advocate strongly for improved services in health to ensure that the issues that we see and will talk about here today do not fall through the gaps in our health system. We deserve a system which is seamless and which provides a holistic approach where the person with mental health problems is central to the health service delivery platform, no matter where they live or who they are.

Mr John : I would like to share why United Synergies is here. A number of years ago we developed a response to a suicide bereavement event that occurred in the hinterland of the Noosa community, in which two family members, on the anniversary of another family member's death, took their own lives. Suicide is a significant issue in our community, and the response we have come up with is really responding to local concerns to address the specific need for the recognition that being bereaved by suicide increases the risk of suicide in communities and particularly among those family members who are bereaved. This response started in 2002 in a formal way to look at addressing those particular needs.

We know that people who are bereaved by suicide have an increased suicide ideation themselves. We know that they have a higher incidence of depression and sadness in their lives. We have been able to develop a program, and the evaluation of it has demonstrated that if we do provide some appropriate intervention—very brief, very early in the process—we can reduce the suicide ideation, the levels of depression and the levels of sadness in those members to below what is occurring in the general population.

In addition to that, what we have found is that when we do respond in a way in which families and members who are bereaved can get that early intervention, then we can improve a number of things in their lives, particularly around presenteeism and absenteeism at work, medical costs and counselling costs—on average in Australia when someone is bereaved it costs about $14,000 to the economy. Our program has been able to demonstrate that it will save approximately $800 per person per year when they have received a brief intervention at the beginning of their bereavement in that space. So not only does it have good social and mental health outcomes for people but it also has an economic benefit for the community in that space.

The program was developed in 2002 and has expanded a number of times. Now we have 16 sites around Australia. The majority of those sites are delivered in regional and remote areas, through local partner organisations who know their communities and are well connected to be able to use the resources effectively in those local communities. Those 16 sites cost approximately $4½ million per year, so it is a very effective, very efficient service for those local communities.

Over the last couple of years we have also seen a significant concern about and vocalisation of communities who are concerned about suicide contagion or suicide clustering. Last year we saw national press around a significant article—a 5,000-word article, which I have made reference to for the senators—on the ripple effect, looking at the suicide clustering contagion concerns in communities. In response to a number of concerns that occurred about four years ago, United Synergies developed an additional response for those communities where there was a significant concern around cluster or contagion in a community and in which we did not have a standby site. It is a program where there is a brief intervention, up to eight weeks, where we can help communities to develop a community 'postvention' plan to respond to concerns around suicide and the number of suicides in a community, and to help them do that in a way that builds capacity, reduces or minimises the harm for potential further contagion of suicide.

We are still very much in the early days around that particular program. We have had about 14 interventions nationally over the last three years from various communities, but the anecdotal evidence we have from working with those communities is that there is a high level of satisfaction and an increased level of confidence for them to be able to respond locally to concerns around cluster and contagion in those areas.

Ms Adams : John Dalgleish and I are representing BoysTown and Kids Helpline this afternoon. We are a major provider of services to children and young people across the country, including many mental health related programs. One such program is the national Kids Helpline service, which is Australia's only 24/7 telephone and online counselling and support service dedicated to children and young people up to the age of 25. Last year we responded to 200,000 contacts from children and young people nationally; approximately 70,000 of those resulted in a young person presenting, which required a formal counselling session with our staff members. Of those counselling contacts, approximately 42 per cent of them were where a young person presented to counsellors with their concerns regarding mental health disorders, suicide and self-harming issues so that number was approximately 28½ thousand contacts—and that is counselling sessions.

In addition to Kids Helpline, we also provide specialist support and counselling to young people participating in the new jobactive program in Queensland, South Australia, New South Wales and Tasmania. Internal research with young people registered with our previous Job Services Australia program indicated high levels of mental illness amongst participants. For example, in one of our previous major offices in the western suburbs of Sydney, 58 per cent of young people who had been classified as belonging to stream 4—that is, young people with high barriers to employment—were experiencing a mental health disorder.

Furthermore, 10 per cent of these young people had also shown suicidal thoughts and/or behaviours and/or self-harming. It is too early to assess but we would maintain it is most likely that the prevalence of mental illness will be at similar levels amongst young people in the newly created Stream C and jobactive programs.

We believe that the mental health service provision to children and young people in Australia could be improved in a number of ways including recognition that young people are not small adults and that the experience of children and young people with mental health, suicide and self-harm is different to that of adults and requires different responses. Policies for the consolidation of mental health service providers should not undermine choice and access to specialist services for children and young people. We believe the resourcing of intensive placement and support interventions within jobactive services for the long-term unemployed young people, predominantly those who are experiencing mental health concerns, would greatly enhance employment outcomes and that the allocation of a proportion of the Commonwealth government's procurement budget to support the establishment of social enterprises employing young people with mental health concerns as a strategy to engage and integrate youth into sustainable employment would achieve great results.

Furthermore, whilst there are elements of integration, we would maintain that there is further opportunity to greater integration and utilisation of specialist providers in the development of safety and recovery plans for those who are identified as high-risk.

Mr Heath : I spent 20 years working in mental health and about the first 15 of those were in the youth area. I would like to reinforce Tracy Adams' comments about the need for youth services to be focused purely on youth. Senators may be aware we circulated a paper to you ahead of this meeting. I do not propose to go in detail through that but what I want to do with your indulgence is just to speak to a couple of highlights of the particular points that are raised there.

In relation to the National Mental Health Commission's review, the sector desperately needs a response this year. We do not want to be in the position where we have funding rolled over for another 12 months. It is just a really terrible way to try and operate services for people with severe needs. When we have seen political leadership in Australia in the past decades—and I would go back to Prime Minister Howard with the work that he did around youth suicide—we have seen significant changes occur. We are not going to see substantial reform in mental health unless we have concerted political leadership around that. I think that at a political level, mental health seems to have dropped off the agenda in the past couple of years. There is an opportunity now for that to be picked up in terms of response to the review. But we need to make sure that those responses are considered and are not done in a simplistic way. At the same time that we have many problems that were identified in the review of the mental health system in Australia, it has been SANE's view for a number of years that we actually believe we have the potential in this country to deliver the best world's best mental health services and programs for a number of reasons but I will not go into that right now.

In terms of the primary health networks, we do support the pushing down of service delivery and coordination to a regional level but we have some major concerns that if you do not design that system right in the first place that we are going to have significant problems down the track in the same way that we had with Medicare Locals. It is not a function of the number of regions that are being applied but the way in which it is being executed. Funding around mental health has to be maintained in real terms. Governments need to understand that how they fund the sector can have particular impacts. We think that government needs to give consideration to what is the right mix of organisations that are funded. For example, in the business community we understand the importance of small business, we celebrate that and that is an engine of growth. But when it comes to mental health, there seems to be an automatic view that fewer is better. So I think this is an issue that people need to take into consideration.

It is critical that the spending on mental health should align with the burden of disease. At the moment, it is tracking at about seven per cent in terms of spending, 14 per cent in terms of burden. We need to have greater investment upstream, especially in the online and digital services. We are still not connecting with around half the people that have mental illnesses and we cannot do that in the ways that we have done in the past. The online world provides an excellent opportunity to do that. Within that environment, there is a huge untapped resource of peer-to-peer support that is available.

In terms of stigma, we have done reasonably well around depression in the past five to 10 years. We have made no progress in the very severe end of the spectrum. SANE Australia earlier this year called for a five-year national stigma reduction campaign. We must have lived experience involved in all aspects of mental health policy formulation, research, system design, promotion, implementation and also evaluation. The life expectancy rates for people with severe mental illness are simply unacceptable, 25 years less than the general public. We need to do much better in terms of combining the work that we do around physical health issues alongside mental health issues. In the past there was an approach which said: let's get your head sorted first and then we will get to your body, and what happened was people never got to the body.

In terms of the National Disability Insurance Scheme, we see this as a highly problematic area when it comes to mental health. We started off in a very well intentioned way. We as a sector accepted an inadequate or improper policy framework that required people to go and plead their disability, which is completely opposite to a recovery model. We did that because we thought there were going to be huge amounts, billions of dollars, that would go to 56,000 people who have got very severe needs and who we desperately want to help. Our concern is that it is now looking like that additional support for those people is going to come off the back of potentially 625,000 people, as identified by the National Mental Health Commission, who themselves have very severe mental health needs. We thought there was going to be a huge bucket of additional funding for NDIS; that bucket seems to be shrinking and potentially disappearing.

In terms of suicide prevention, we have a sector that is united around suicide prevention in a way that has never operated before. We do support the rolling out of programs on a regional basis but that does not mean that we should not be doing anything in those other regions. So we support the continuation of support to national organisations working in that area. We must continue to fund innovation. There is a notion that if something is evidence based that it is the only thing that should get funded. Every single program service that is now evidence based was at one point in time not evidence based. There has to be funding in innovative and promising services.

Finally, this is a little bit of an outlier. SANE Australia is involved next week in hosting a number of events with a former British parliamentarian. He is chair of the all-party parliamentary group on mindfulness. Around half the members of Westminster have actually undertaken mindfulness based training. We are so far behind the UK in Australia. Admittedly there they have the Oxford Mindfulness Centre, which gives legitimacy to it. When I speak to people with lived experience and psychiatrists, mindfulness based practices are being used right across the board. Mindfulness based practices have not yet captured the attention of policy makers or people working in the Department of Health. There is a huge opportunity here around cost saving.

By international standards, we are doing pretty well in Australia but we are so far short of what we could be. We genuinely believe that Australia has the potential to lead the world in mental health services, programs and outcomes as well. We have a sector that is united like never before. We now need political leadership that helps us move forward.

Prof. Proudfoot : I will speak just a little bit about the Black Dog Institute and then I want to concentrate on two areas that we are particularly concerned about. The Black Dog Institute was founded in 2002. We specialise in the diagnosis, treatment and prevention of mental illnesses such as depression, bipolar disorder and anxiety. We work to improve the lives of people affected by mental illness through very rapid translation of research—that is, our own research—plus we also do systematic reviews of research conducted internationally as well. We translate them into improved clinical treatments, increased accessibility to mental-health services and delivery of long-term public-health solutions.

We all know the statistics that one in five Australians experience a mental illness each year, and each day at least six Australians die from suicide. They are horrendous statistics. We at Black Dog Institute focus on incorporating clinical services with cutting-edge research, health, professional training and community-education programs.

I have given you this document so I will not go through it in detail. Just to give you a snapshot, in 2014 we ran 20 clinical trials. We published 136 peer reviewed papers. There were 26,000 people who attended our education program for health professionals for community. We developed, delivered and evaluated e-mental-health programs, which are programs that use technology for developing, delivering and evaluating prevention, early intervention and treatment programs for people with mental-health problems. Our six clinics saw 1,500 patients and we prepared six policy documents. As I said, I will not go through the annual report, because it is all there.

There are two areas of work we do that I want to highlight to you, today. The first is that despite ample evidence that suicide is preventable, suicide prevention is cost-effective and Australia was one of the first countries to develop a national suicide prevention strategy, in 1995, suicide rates have not declined significantly in Australia in the last decade. In fact, in the last 12 months the numbers have increased, particularly in young girls and Aboriginal and Torres Strait Islander men. Progress in this area has been hampered by the lack of integration and poor coordination of suicide-prevention activities and strategies. There has been activity there and a lot of good activity but it has not been integrated or coordinated.

Evidence from overseas shows, very clearly, that successful suicide prevention requires a simultaneous systems based approach that involves multisectoral involvement by all government, non-government, health, business, people with lived experience, and education, research and community agencies and organisations. That is, it needs multiple points of intervention. Within a localised area, having done an audit of what services are available in the localised area, it means implementing evidence based strategies, at the same time, that are effective and demonstrating sustainability and long-term commitment.

The implementation of a systems based approach—based on overseas results, where the data have been very impressive—being much more conservative than that, we project that a systems based approach to suicide prevention is likely to reduce suicide and suicide attempts by 20 per cent in one to two years. I have provided copies of this document for you. I have also given you the proposed framework for suicide prevention. The Mental Health Commission of New South Wales launched this two weeks ago. It was developed by the Centre of Research Excellence in Suicide Prevention that Black Dog Institute hosts, and the document is available on our website.

That is the framework. It has now been submitted to the New South Wales ministry, where it is under consideration but has not been adopted or funded yet. The National Mental Health Commission, of New South Wales, has funded Black Dog Institute to develop a detailed implementation and evaluation plan. At the launch, two weeks ago, the participants committed to reducing our suicide rate by 20 per cent within four years, implementing the national suicide based approach and advocating for implementation to begin, immediately, in 12 identified high-risk locations.

The research shows there are nine strategies that are evidence based and effective. The most promising of those is restricting means to suicide, GP education and gatekeeper training but, of course, they need to be fine tuned and tailored to the particular local area. The economic cost, apart from the very traumatic personal cost, is $17.5 billion, annually, to the Australian community. So it is really timely that we do something about suicide and suicide prevention.

The second area that we would like to present today is that of e-mental health—that is, the use of technology, as I said earlier, to develop, deliver and evaluate therapeutic intervention and prevention programs. As we know, less than half of the 4.4 million Australians who experience mental illness each year access formal help—less than half receive treatment. The reasons are varied: stigma, financial limitations, geographic isolation, lack of clinical services, or workforce in particular areas, shiftwork, which makes it difficult to get there. Australia is a world leader in the development and delivery of e-mental health services. They range from interactive websites, apps, online crisis counselling, sensor based monitoring and psychiatry via Skype. There are many advantages; I will not go through all of them because they are outlined in this document I have provided for you. I have also given you the programs that we have developed at the Black Dog Institute.

I would like to say that, apart from it being available 24/7 to enable those in need of support and to assess risk factors in real time, there is a strong body of evidence worldwide demonstrating the clinical and the cost effectiveness of e-mental health programs for mild to moderate depression and anxiety, insomnia, alcohol and drugs, as well as suicide prevention. Controversially, there have been trials which show for these mild to moderate conditions that e-mental health programs are as effective as face-to-face therapy. The other great advantage is that they translate to real world conditions, and research, both ours and international, has shown that they do improve work and social functioning. They do not just reduce symptoms; they improve work and social functioning. This means that fewer people need to be referred to secondary and tertiary services.

We have done some cost effectiveness analyses as well. We considered a fully-automated program—that is, without clinician support—but tailored to individuals, and it was about half the cost of antidepressant medication and about a sixth of the cost of face-to-face CBT. They are available; they are effective, but to date they have not been integrated into a stepped care model or into primary care. That was one of the recommendations from the National Mental Health Commission.

The Black Dog Institute is now implementing a pilot study: we are trialling assessment or screening triage of all patients in GPs' waiting rooms, using tablets and providing real-time feedback to the patients and to the GPs, along with treatment recommendations and a stepped care model so that patients will continue to be monitored every fortnight. If they are not improving, recommendations will go back to the GP to step up the treatment. The first step is e-mental health for very mild symptoms of depression and anxiety. For those with more moderate symptoms, the recommendation would be face-to-face CBT or treatments, and for those who are even more severely depressed or anxious it is going to be medication or seeing a psychiatrist.

Our recommendations are that: e-mental health needs to be integrated into a stepped care model; there needs to be multiple access and referral opportunities; and we need to raise community awareness about e-mental health. We have done some modelling to show there are 700,000 Australians who are eligible to receive e-mental health treatments, and that would prevent some of them from going on to require other forms of treatment, thereby freeing up health professionals to treat more severely ill people. We also need a funding mechanism. I will leave it there. Thank you very much.

Ms King : Hi, everybody. Thank you very much for letting us be part of this process. Anglicare Sydney do not have a large number of mental health services but we do have some. We have some in relation to respite services and some early intervention services. We have our Personal Helpers and Mentors program. We have some mental health programs. Narelle is going to speak today from the practitioner's perspective, but I want to say a couple of things.

We are a large provider of a broad range of services, like the Salvos, to the most marginalised and socially excluded people in our society. We are finding through our emergency relief centres that mental health is one of the most significant issues facing people who are really socially excluded. We are finding that people who are on the verge of homelessness or are homeless frequently have a mental health issue. We did discover back in the 1990s that only about 10 per cent of the people coming through our emergency relief services actually had a mental health issue. By about 2002 this had ramped up to more than one-third of our clients coming through. We have about 14,000 clients a year come through our sustainable living services. Mental health, therefore, is a really significant issue for a lot of people coming through our services.

Anglicare Sydney is one of a network of seven Anglicares that operate across New South Wales. The other Anglicares, who I am sort of representing today, are very concerned about the lack of acute mental health services in regional and rural areas. We have spoken to the state government on this issue on a number of occasions. There are very big concerns about the lack of those sorts of services in those areas.

There are two policy areas of concern. We are very concerned—and Mr Heath has spoken about this—about the NDIS and where exactly people with mental health issues fit into the NDIS. I have had some fairly high-level discussions with the New South Wales government on this. There seems to be concern at a number of levels that it is not really clear how mental health is going to come in under the NDIS and what that means. We are very concerned about the people who are going to be perhaps defunded. These services may well be defunded and there may well be no other options.

We have got two or three areas of policy that we would like the government to think about. First and foremost we would like to make sure that no-one gets discharged from hospital, custodial care, mental health or drug and alcohol related services into homelessness, because for many of our clients that is exactly the case. Access to stable and safe places to live actually has to be part of a mental health solution. We are also very concerned that with the growth of the NDIS there may well be defunded mental health services. We want to be assured that national systematic and adequately funded early intervention approaches remain, because we understand the depth of the problem, particularly in the areas in which we operate.

I think that is probably all I really want to say because, as I said, we run a broad range of services and are a $105 million organisation. Mental health issues thread through most of the work we do in terms of emergency relief, sustainable living, family support services and respite services. We also have a large carer population that we look after. There are some significant mental health issues among our carers, particularly among our ageing parent carers. We have five ageing parent carer programs operating across Sydney. We have done a detailed evaluation of that and there are definite signs of anxiety, depression and stress. For carers that is really high. I would be more than happy to speak about that further if anybody is interested.

I will hand over to Narelle, who is going to give a little bit from the practitioner perspective.

Mrs Hand : Thank you, senators, secretary and fellow colleagues. I run three mental health programs for Anglicare and have done for a number of years. The Personal Helpers and Mentors program, which I feel is of such fantastic benefit, is a psychosocial support program. This program is at risk of being defunded and being represented under the NDIS. Our concern is that many people in our program may not be eligible for NDIS packages. We have been attending all of the consultations that have been rolled out in the Hunter region and the evidence that has come back is that at some stage it might be that only 20 per cent of the participants we currently have will be eligible for those packages. Our concerns are that the people who are not eligible will fall through the gaps.

Psychosocial support is an absolutely fantastic recovery based support for people with mental health challenges. We give one-on-one support. We prevent people from engaging in the hospital system. We work very closely with Partners in Recovery, hospital clinicians, psychiatrists and psychologists. I think that at times this particular program has been a little bit undervalued. We prevent people from re-entering the hospital system by working extremely closely with them to ensure that they are working towards recovery and sustainability of health. We are extremely passionate about this. Given the statistics that have already been noted—that one in five people experience a mental illness in one year—this is something that really needs to be supported in the future. We give practical support. We give education support to people.

We have concerns about the rollout of the NDIS. For people who are eligible I think it is an amazing program, but I really fear for people who are not eligible. We have a lot of people with depression, anxiety, eating disorders—with symptoms that may not necessarily be severe and persistent at all times. These are the people who will re-enter the hospital system if these supports are not available.

So I suppose I am here advocating for all of the PHaMs programs. I think this program has perhaps not had as much advocacy as it should have. Personally, I think it is an amazing program and I have seen some amazing results from people we have worked with. I would like to share with you, if I may, one case study that we have permission to disclose today. The participant is a middle-aged single lady. She was admitted to hospital with severe depression and anxiety. Leading up to this she had lost her job. She was not able to pay her rent. She became homeless and lived with different friends. She was discharged from hospital and tried to find support. She found out about our PHaMs program and referred herself. That is another benefit of this program—you can refer yourself.

Her goals were to find stable housing and to finish her university degree. She had been enrolled for some years but, due to her mental health, she was unable to complete the course. During her involvement with PHaMs, she received intensive support in managing her anxiety and depression and addressing issues related to finances and housing. She was able to access stable housing, which was a major breakthrough for her. Our PHaMs workers offered weekly support and later fortnightly support in managing anxiety in relation to social situations and the completion of her university degree. Initially it seemed impossible for this participant to be able to complete her degree and the PHaMs worker employed different strategies to help improve motivation and structure so that she could finish her work.

She experienced regular major depressive episodes, including suicidal ideation, but with the support of the PHaMs worker and her psychiatrist she managed to get through the crisis and did not require any hospital admissions. Her depressive episodes became less regular with time and, in consultation with her doctor, she stopped her medication.

The participant was able to complete her university degree, which improved her confidence, and following on from this she began to reconnect with friends and relatives. PHaMs played a major part in supporting this participant when she was not able to manage most aspects of her life due to severe depression and anxiety. She has achieved a much improved quality of life, which she deserved, and her mental health has been so much more stable. This is just one of, I would imagine, thousands of stories from PHaMs that have been achieved. I would really like the Senate to take note of this today.

Prof. Littlefield : The Australian Psychological Society is the peak national body for psychologists. We have 22,000 members, which is the major proportion of psychologists in Australia, and psychology makes up the largest part of the mental health workforce. We put in a broad submission to you last year, but obviously today we are focusing on mental health. I would like to focus on the systems level, particularly on programs that are funded by the Commonwealth.

People with mental health problems are very varied, but we know from clear data that 80 to 90 per cent have what we call high-prevalence problems, with anxiety and depression as the major ones, whereas 10 to 20 per cent have low-prevalence problems, which are schizophrenia, bipolar disorder et cetera. They are the people that really do have chronic and complex conditions. We need to keep these people out of the acute settings as far as it is possible to do so. It is not always possible, but as far as possible. To do that we need to provide more services in primary care. For these 10 per cent of people, we need in primary care an increase in integrated and coordinated clinical and support systems. That includes more extensive funding for psychological services, which now have a good evidence base of being able to treat these people. We agree with a lot of what the mental health services review has said. In general we believe in a stepped care model—we think that is really important—and to shift funding as far as we can down the spectrum of services from the expensive acute end down to the mental health promotion-prevention end—and, of course, with primary care being the big bulk of things in the middle of that spectrum.

I will talk a little bit about different parts of the spectrum. Our argument is: the earlier you identify people that have symptoms of mental health problems and get them to effective treatment and services before their condition worsens and gets more serious the better it is for them. There is a decrease in suffering and a decrease in cost to the mental health system. We think more money should go into mental health promotion and prevention. That should start at a very early age. You can pick up children in child care and in schools that are showing signs of mental health problems, which will go on to develop. We think it should be in places that are already accessed by the whole population like workplaces. There should be mental health promotion and prevention there—even in aged care. It is really worth doing it in aged care. We are advocating putting more money into that to stop the escalation of mental health problems.

In the primary care system itself, we think that at the point of entry—at the moment it is mainly through GPs—there should be a much more effective assessment process so that you understand when the client comes into the system exactly what their problem is. They are often multifactorial. You might have anxiety, depression or whatever, but it could be due to your own biological vulnerability; it could be due to a family situation, a work situation—a whole range of things. Unless you have a proper assessment, the treatment pathway is not clear. If you want a very effective and efficient system, that is critical to pick up what their most appropriate treatment pathway is.

At the point of entry—let us say it is the GP—what the GP should be able to do is pick up the degree of severity of a disorder. If it is mild, we totally support the idea of e-therapy. We think e-therapy is a very good starting point for someone with a mild disorder. We particularly support therapy-assisted e-therapy, which could be a 15-minute telephone consultation each week, or something of that nature. We think that to be able to pick those people up and get them that form of treatment would save the system a lot of money.

If their disorders are amongst the group we call the high-prevalence disorders, which are largely anxiety and depression, the pathway at the moment that is funded under Medicare is Better Access. We see that as very effective and cost-efficient pathway in that the GPs can refer straight to psychologists and other mental health workers. The evaluation shows very good treatment outcomes. Even people with severe conditions—and we have studies on this and we can give you data—are reduced to mild symptoms or even no symptoms at all. It has good treatment outcomes.

The only problem was that the sessions got cut—I think it was two years ago—and the extra six that were there for people with more difficult-to-treat conditions got cut. I am talking about people with problems such as eating disorders, obsessive-compulsive disorder, or post-traumatic stress disorder. You cannot treat them usually in 10 sessions. You need the extra six. At the time of cutting the sessions, from the Medicare data, 33,000 Australians were left without sufficient treatment and they had nowhere to go. What happens then is they go downhill. You wait for the next year when you can get into the system again and you have to start from a poorer baseline. We think those sessions really do need to come back.

The other system is the ATAPS, Access to Allied Psychological Services, that is now run through the PHNs but was previously run by the Medicare Locals. We think this is a very good complementary system, particularly for people in niche groups like homeless people and Indigenous people, where you need more flexibility in the system, like longer sessions and the ability to do outreach, that a Medicare funded system does not allow. We see the two things as being very complementary and we believe that that should continue as well.

The only problem with ATAPS, and it is a looming problem at the moment, is: should the Medicare Locals have run it? Now we are transferring it over to primary health networks. We found, as the prime deliverers of that service, that there were a lot of problems in the Medicare Locals running it. I can talk more about it, if you wish. They did not manage it properly largely because the staff in them did not have any mental health knowledge, so they did not know who to refer to for what. They were not able to monitor. They were not able to look at the quality of services. They did not consider safety aspects. We are worried that the primary health networks will do exactly the same because they are not particularly well funded. Therefore, what will the quality of their staff be like? Will they make the same sorts of mistakes that the Medicare Locals did?

However, we do see a role clearly for the primary health networks in the coordination and integration of the more complex care that people need. We can definitely see that that is a role they could take where they have to get clinical and support services et cetera together and coordinate them. Our question there is: how do you do it from something that is central when they have huge geographical areas? A system would have to be worked out as to how you get out from a central PHN—a hub-and-spoke model, or something of that nature—because you need to tailor these services to the local community, by and large.

I have given a relatively brief set of points, but I am happy to elaborate on anything that you are interested in.

ACTING CHAIR: I would like to thank all the witnesses for their opening statements. We received three lots of documents—one from the Black Dog Institute, one from the Salvation Army and one from United Synergies—to be tabled. Does the committee accept that?

Senator McLUCAS: Happy to move that.

ACTING CHAIR: Thank you.

Prof. Littlefield : Are we able to give you an adjunct—do you accept that?

ACTING CHAIR: A supplementary submission?

Prof. Littlefield : Yes.

ACTING CHAIR: Yes you can table that if you want.

Mr Heath : Can we ask that our document be tabled as well.

ACTING CHAIR: That document has already been published.

Mr Heath : Okay, sorry.

ACTING CHAIR: I will jump to Senator Williams.

Senator WILLIAMS: Thank you, ladies and gentlemen, for your presence here today. I have had concerns for some time now about our whole approach to funding, financing and addressing mental health. I live in a rural area and I see a lot of people affected by drought. A lot of people who come to my office have financial problems with the banks. I probably do more work with the banks than any other politician in this building. My concern is that we have this scattergun approach where we throw a bit of money out to all these organisations. I look around the room today, and we have about 10 lined up today. That does not include Centacare, SCARF or headspace. Mr Heath, I understand where you are coming from as far as living in limbo is concerned—whether you are going to have finance next year. Is there any push to bring all the groups together and centralise, starting off with the care of our kids at three or four years old—which, we found out earlier this morning, is where the trouble actually starts in many cases? How can we get a better bang for our buck with the taxpayers' dollars or the money we are borrowing to deliver these services and make it more efficient, especially in a case where, according to the Digital Dog pamphlet here, statistics show that less than half of all Australians experiencing the symptoms of mental illness will access formal treatment? We have serious problems: people out in a drought, broken families and kids being neglected. What I am worrying about is that we are just turfing money out here in a scattergun approach and we are not getting the best results. Am I off the money or am I on the money?

Mr Heath : I think your call is correct. In fact, this is what the National Mental Health Commission pointed to in their report. My work in this area started over 20 years ago when I lost a young cousin to suicide on our family farm, so I can certainly empathise with you on the challenges that are faced by people in rural and regional Australia. Some of the organisations here are collaborating in a way that is better than has ever been done before. The sector is probably more united than it has ever been in the past, but you also have to understand the dynamic of how you put money out if you have a whole lot of organisations. You will obviously have witnessed the passion from people in this room and all the other areas where people are working in mental health. If you say that there is only a certain amount of money that is there and you only have it for 12 months, it sets up a dynamic where people are just in survivalist mode. We are thinking: 'How do we get through the next 12 months? Are those people going to have a job?' So, when you set up that sort of funding framework, it actually militates against people being able to sit back, take an overall perspective and then think strategically about how it is that we could work together.

Having said that, at SANE Australia one thing that we have done over the last 12 months is to go and launch an online platform for discussions where people in rural and regional areas across Australia are able to sit down and talk to peers about mental health issues. We have been able to establish that in partnership with 24 mental health organisations around Australia. I think the sector is actually starting to work really well together, but we need some clear political leadership on where the government thinks things should go. I think that you have a more united mental health sector than we have ever had before, and we are very willing to look at ways that we might cooperate together. I am not sure if my colleagues want to add anything.

Mr Dalgleish : I would like to add to that if I may. I come from an organisation that is 70 per cent self funded, so a lot of the work that we do we provide through our own fundraising efforts. I agree with Jack's comment there about the greater collaboration occurring. I think Kids Helpline provides a safety net for children across Australia, at virtually no cost to the government. Agencies in the field can include us in their safety plan or recovery plan for children, and then we can provide that 24/7 support to them. That is just an example of the collaboration that can occur.

But on consolidating the sector, which has been a policy raised in the review, I reiterate our CEO's comments before. We do not want to consolidate and throw out the baby with the bathwater. We cannot consolidate and lose the specialties that are so important for children and young people experiencing mental health problems. We know that children and young people find difficulty accessing help services, but one of the things that enables them to do that is feeling that that service knows them, knows their culture and knows the drivers to their mental health issue and the triggers for their suicidal behaviour and can intervene and provide specialist care and support. So, in consolidating the sector, it would be a backward step to take out all the specialties that already exist.

Prof. Littlefield : I would like to take it from a slightly different point of view. Regarding the point about getting in early in child care and in schools, there is a Commonwealth funded program—I do not know if you have heard about it—called KidsMatter, which is in 2,600 schools. It is to do with health promotion and prevention, getting skills for kids into the curriculum so that they do not develop mental health problems, getting the parents involved, picking the kids up—

Senator WILLIAMS: Isn't that the big issue—getting the parents involved?

Prof. Littlefield : A very big issue.

Senator WILLIAMS: When a baby is born, to me it is the parents' responsibility to rear the child properly. Bring the parents into training courses or whatever, so that they look after the child, would be a good start, wouldn't it?

Prof. Littlefield : And I think it is really good to be in schools and child care because it is non-stigmatising. They go there; part of their daily life is to go to these places. It is about teaching the teachers how to talk to them if the children are showing problems and, if they are seriously in need of some professional help, they can refer straight to a psychologist through ATAPS, without going through the GP. That is important because families do not always like to go to a GP and say, 'My kid's got a problem,' because they feel it reflects on them as parents. So it is about getting in early, destigmatising it and putting things in places where people feel comfortable going.

Senator WILLIAMS: Getting in early is easier said than done. If you start sticking your nose in the door of a young couple rearing a two-year-old and telling them how to rear their child, they are going to tell you where to go, aren't they, unless they ask the help?

Prof. Littlefield : But 90-something per cent of kids now go to child care. In child care, parents are used to talking about their kids and asking the childcare workers what to do for this and that and the third thing. In that context, it does really work.

Senator WILLIAMS: What I am saying is: how do we get the most efficient results? We do not have an unlimited amount of money. We have a budget; we cannot just throw in another $50 billion in the next 12 months and say, 'Here, fix the problem.' What I see we have to do is get your ideas of how to best fix the problem, and some of the statistics coming forward are very concerning.

I have the greatest respect for the Salvation Army. I launched your caravan a few years ago in Inverell. It drives around the farms and stations and talks to the people and does a great job. You said aged-care facilities are reluctant to admit those with mental illnesses.

Mr Bewert : Yes.

Senator WILLIAMS: Why?

Mr Bewert : There is often a complexity that comes with the appropriate management of a person with a significant mental illness, particularly if it is not controlled. The support that is available through the local hospital health networks often is not forthcoming once a person enters into residential aged care, because, unfortunately the attitude is: aged care is funded to look after that person in that context without the specialist knowledge to provide for those individual needs. That links back to what my colleagues were saying. Mental health in Australia is a growing concern, and it affects the generations that we have within Australia. There are very specialist services that need to be provided to best meet the needs of each of those people across the Australian public. No one organisation can truly meet all the needs of what our community requires. Certainly, from an aged-care perspective, I think mental health will become a more complex and challenging issue because we are seeing more and more older Australians diagnosed with mental health problems. The latest stats, which I received before coming here, show that one in three persons in our residential aged care facility has a diagnosis of a mental health problem.

Senator WILLIAMS: I hear so many terrible stories about this drug ice—people going off their brains on it, bashing the ambos, the police and the nurses, and just losing control of themselves. In any of your organisations, are you getting information that this use of illicit drugs is also adding to these problems of mental health?

Mr Bewert : Absolutely.

Mrs Rosenthal : Can I pick that one up?

Senator WILLIAMS: Yes, certainly.

Mrs Rosenthal : Being a residential aged-care provider, I will hold the ice question just for a sec but link back to your question about why other residential aged-care providers cannot cope. We had a man who came into one of our centres who had been diagnosed as a chronic treatment-resistant schizophrenic in 1973. He had been in hospital every year since that time for anything between 18 and 34 weeks of each year. He had multiple failed residential placements. He had failed in dementia-specific locked units. We agreed to take him on. He had multiple delusions, which were that he was a 15-year-old girl; he had period pain; he was in an orphanage; he owned the orphanage; he was in jail; there were people who would beat him up—and those delusions were present four to five times a week with this man. His behaviours could be very aggressive verbal behaviours, physical aggression, physical self-harm—he would be bruised and covered in scratches and bruises and cuts and things. For a generalist aged-care centre which is trying to deal with what I would call the tea-and-toast resident, who is a nice little old lady in her pearls and her pink cardie, that kind of behaviour from somebody like him is not going to win him any friends or influence people or create a connection and community within the area where he lives. So bear that in mind.

In the Montrose Men's Home, which I mentioned before, over 40 per cent of those men have had a long history of substance abuse, drugs and alcohol, coming out of recovery services. As an aged-care provider we are not seeing the ice epidemic, but we are seeing the results of hallucinogenic drugs and long-term cannabis use, and it is something that we manage day to day in our centres.

Mr Bewert : Yes, we manage that every single day in our centres. Just this week we had a case at one of our specialist homes where a person had acquired illicit drugs and was trying to sell them to the cohort of residents within the home. That is something that our staff face on a day-to-day basis in a residential aged-care context. It requires a very specialist knowledge and very strong community links to effectively manage that, because there are very strict guidelines on us about how to manage people. We cannot simply turn around and say: 'Sorry, you're selling drugs. Off you go; you're out.' The legislation in aged care does not allow for that. The complexity of management of those situations is not the norm, but it will become the norm with our ageing population and an increase of people coming into homes like this with mental health problems.

Senator WILLIAMS: So the more drugs today, the more problems later?

Mrs Rosenthal : Yes.

Mr Bewert : Absolutely.

Mrs Hand : Just in reference to people reaching out to services or not reaching out to services, I think that, with the amount of stigma that is associated with mental illness, it can affect your employment; it can affect family; it can enforce isolation. People do not necessarily want to re-enter an acute-care hospital ward if they have already been in one prior, which I think is something that people really identify with. They actually, I think, fear engaging at times with services, in that they will lose their power and they will lose their control.

On the overlap of services: when we have funding going to services like Partners in Recovery for people who fall through the gaps of mental health and then we have Ability Links, which works with people with mental health issues, it is kind of like there is money being spent in areas where there is probably not a service gap. It seems to be a little bit imbalanced.

But, as far as people engaging are concerned, we need to break down the stigma so people reach out. We need to make sure that when people apply for positions, if they have mental health issues, that is not going to affect their not getting employment because of the workers' health and safety risk. They are the kinds of messages that may prevent people from disclosing or reaching out.

Mr Heath : I will just add to that, if I may. In terms of the issues related to ice, we have to be careful and smart in how we communicate messages to the general public. Going to this issue of stigma: we have seen a number of advertisements that have been put out across national media dealing with someone who has an ice issue who is 'psychotic' in a hospital. This actually creates a stigma around people who have an ice issue.

In New Zealand, they were able to halve the ice usage rates by having public messaging which told stories of how people got off ice. When we provide messages of how people deal with problems, rather than focusing on the dramatic consequences or the most extreme examples, that is when we start to see shifts happening. So, in terms of doing things around ice, it is really important that we are focusing on how people actually get help, because if I am taking ice and I do not think that there is any hope, if I do not think that there is any chance of getting to a better place, I am probably more likely to go and be violent. So we need to get our public messaging right around issues like ice. A lot of it is about reducing the stigma so people understand what the situation is and where and how you can go and get help, and that is what will reduce the ice usage rates.

Senator WILLIAMS: And education at the start not to get on it.

Mr Heath : Absolutely.

ACTING CHAIR: What you say about the ice there is really interesting. We touched on a question there—I will get to you very soon, Senator McLucas, by the way.

Senator McLUCAS: No, you are allowed to have some time!

ACTING CHAIR: As far as the ice problem goes, we touched on ice causing mental health problems into the future, especially when it comes to aged-care retirement facilities and so on. I suppose the other part of the question which we did not address was before people end up on ice and mental health issues actually leading to that as well. Does somebody want to have some input on that?

Mrs Hand : Yes. Being a practitioner and engaging with a lot of people that may present to our service with those kinds of situations, I have to say that, in my experience, most people that we have been presented with have had extremely traumatic pasts. There is a history of perhaps child abuse, sexual abuse, trauma. I would be very surprised at someone that would come having some form of addiction without having some kind of a trauma. We have had people present in our program where they have been on eight-hour ice binges and ended up in hospital and actually have been discharged from hospital, still with psychosis symptoms and suicidal ideation, and have not been able to re-enter the hospital system when they really need that high level of care. I think it is a huge, complex issue, but I think it is the early intervention, prevention, education and support and all of the services working together and sticking to what our specialised areas are—Anglicare, PHaMs; we are psychosocial support. We work closely with hospital, clinicians and psychologists to bring that together to make sure that that person has support. If they do not have all the supports in place, how can they succeed in the recovery?

Mr Dalgleish : To add to that: I think also we need to look at the social circumstances of those children and young people, because in our experience, across our services, where we provide services in some of the most disadvantaged areas in Australia, it is the fact that children have lost hope. They are not engaging in school. They fear or they see that there is very little hope for them to get a job, given their educational history and given their lack of employability skills. They are in a hopeless situation where they turn to those drugs and other activities as well. So I think that, as well as personal trauma, we need to look at the social situation of children.

As in our opening address, I think that one of the big areas in Australia where we could make a very practical reduction in the impacts of mental health issues is in the whole area of our jobactive programs. For young people who are often being classified as in stream C with mental health issues, providers do not have the resources to engage those young people in activities that would help them recover from the mental health issue and then get the skills required for them to get a job. We are currently losing a whole generation of young people who are sitting in that system, who have no hope of getting a job unless we provide that support.

We have evidence internationally and nationally. We know how we can engage those young people to get them work. We know that intensive personal support interventions being used in America, being used in New Zealand and being used elsewhere, where you have smaller case loads, where you have a dual case management model—where you have a specialist employment consultant and a specialist youth worker well versed in mental health issues working together in a case management model—produce results with very little investment. I take the senator's point before: government does not have an open purse. We understand that. But if we can look at this in a systemic way, I think you can get more social and economic value by practically intervening with those young people who are currently just sitting idle in our Job Active program because the help is not there and by encouraging their recovery through work rather than what we are currently doing in some other areas. I think having that system overview and looking at priority areas for intervention is the way forward.

ACTING CHAIR: I suppose at this point I had better declare an interest. When I was 15 years old I rang Kids Helpline. I actually gave Kids Helpline a call when I was in my mid-teens.

Senator WILLIAMS: Did it help?

Senator McLUCAS: I thought you said you ran it.

ACTING CHAIR: No, I did not run it; I rang it. Senator Williams raised a point earlier that caught my interest. We have got a lot of different organisations scattered around everywhere. Why can't we centralise them? That helped highlight the point that if you all have your own little specialties it can help you tailor your service to the needs of those certain areas, and I am thinking about rural areas in particular now. With the current way that the mental health system is set up, is it really possible for things to be tailored to certain areas? Out in the west of Victoria it is dry desert and there is a certain type of lifestyle, while in my area in Gippsland it is quite wet, and there are big differences in the issues that people face.

Ms King : I am finding the discussion about trying to have a centralised system—maybe a silver bullet—that is going to solve the whole problem really interesting. I think the issue with mental health is that it is incredibly complex and it is very nuanced. Therefore, it is not easy to have one simple solution. You are talking about mental health across a range of things. You are talking about mental health in the early years. You are talking about early prevention. You are talking about early intervention. You are also talking about managing people who have episodes. You are also talking about people whose illness is chronically severe and who need a whole lot of help. You are talking about people at the other end of the spectrum who may need just social support and some periodic intervention. So you cannot really have one service that is going to meet that spectrum of need. Because it is a complex problem, it needs a multipronged approach, and it does need specialist support, particularly at the local level.

Senator WILLIAMS: You might have 20 organisations. Couldn't we just have one or two where they have all those specific services within their group? Many organisations like the Salvos et cetera are run by volunteers, and the more organisations you have, the more CEOs you have, the more administration officers you have. It appears to me to be just like having five tiers of government in Australia. If we had that it would be just ridiculous. It would be overlapping. This is the point I am getting to: is there a way to make it more efficient with the dollars we have available?

Senator McLUCAS: Can I ask the question differently? I refer to the Mental Health Commission's review and their recommendation around regionalisation of services. Instead of just funding in a scattergun approach, to use Senator Williams's words, we have to think about Australia as a set of regions. We need to think about what the mental health need of each region is, what service array currently exists there and what do we, as a Commonwealth government and as state governments, need to do to serve that population. Then the ability to navigate that system is within a local context. A person with a mental illness does not need to navigate a system; rather, they need to get help and support at the right time. I am trying to pose your question in a different way, if that helps.

Mrs Rosenthal : I think from my perspective there is a need for an understanding of what Susan said about mental health being, for some people, an episodic, one-off event, while for other people it is whole-of-life, chronic ill health. Therein lies the challenge in terms of one centralised provider of services, because if you are looking at everything from your average three- or four-year-old right up to the 97-year-olds that we see the way that we provide care in each stage of life is very different. Children are not small adults, I think you said. The other thing I think is very important is not losing local flavour. Karen and Christopher were mentioning before that local knowledge of how a community works and what the needs are in that community cannot be met by one centralised overarching mental health provider.

Prof. Kyrios : There is a set of outcomes which joins us all. They could be deepening suicide rates, wellbeing, life satisfaction, symptom reduction, jobs—there is a whole range of them. These can be regionally nuanced because in some areas suicide are higher—for particular age groups they are higher and what not. I think the problem is that we do not have an agreed set of outcomes. We do not measure outcomes. We do not have an agreed set of measures of these outcomes. So we do get this scattergun approach and we get policy on the run, as distinct from evidence based policy. We have seen evidence being collected by various organisations and by various research centres. Greater integration with the expertise that academics and research centres offer, greater engagement with professional groups who know what the specific measures are for each of these areas, this is a way forward and a way of bringing it all together. But you can still have this nuanced approach, whether it be regional, whether it be sector or whether it be problem area.

Senator WILLIAMS: And most importantly, not having 20 groups asking whether they are going to be funded next year.

Ms Adams : Could I perhaps put a slightly different perspective. I think there is a need for localised and building up. People know their local communities. They can form linkages and pathways and organisations that are nationally based can be used to support those. Perhaps another framing here does need to be considered and that is the level of integration across government and governments because if we are talking about measures and using these, we actually do not have consistency in the way governments are operating. I even think if we think of mental health, it does not just belong to the department of mental health or to health; it is in employment, it is in education, it is in aged care, but it seems to me that we do not consider it. So integration needs to be considered on both sides of this argument, or investment, because we are linked to a common bond of wanting outcomes that will improve our communities. We are all part of community, as is government.

Senator McLUCAS: Can I ask you a question that follows on from that in recognising that there are already three hands up. Earlier today we heard evidence from the commission and then from another roundtable. In both of those sessions we talked about the fifth national mental health plan, to try to pick up your point, Professor, and yours, Ms Adams, that mental health does not sit in the Department of Health, and the commission's report is very strong on the fact that it is a whole-of-government approach to working collaboratively, where does the fifth national mental health plan fit in our governance arrangements? Does it sit in the Department of Health, as the first four have, or should it be endorsed by COAG, first ministers? I am just throwing that out there as something to think about.

Mr Heath : It has to be picked up by COAG. The only time we have ever seen significant reform of mental health is when there has been political leadership at the prime ministerial level. So the notion that it is going to get stuff happening by being passed off to the health minister or to the mental health minister, when they are having to compete in cabinet to get funding for particular projects, by parking it off in that area you are going to set yourself up to make it much more difficult to get the level of support that you need from your colleagues.

Senator McLUCAS: Hansard does not recognise nodding. So for the purpose of Hansard, I am saying that nearly everyone around this table is nodding. This is called gathering evidence.

Mr Heath : Touching on what Professor Kyrios said, there was an expert reference group formed a number of years ago, of which I was a member, convened by the National Mental Health Commission, which put the case very strongly for setting up specific targets and indicators by which people which be measured. It was people in the sector, organisations like ours saying, 'Let's set some goals and we want to be held accountable.' We were saying to government, 'We want to be held accountable for particular outcomes.' So we need governments to sign up to these targets and indicators, and they need to be long term. If government is prepared to do that, you will find the sector rallying behind, wanting to be accountable and wanting to work together well. But it requires a partnership from political leaders and from the sector as well.

Prof. Proudfoot : And not just activity based measurements but also definite outcome measurements.

Mr Bewert : They need to be measurable outcomes. As Ms Adams said, the issue of mental health is one of those things that crosses all boundaries. It comes across all government departments. It comes across multifacets of everyday life. So, to park the management of a national mental health plan within a specific department such as health, all of a sudden there is an exclusive process that then occurs within other areas. It has to sit with COAG. I cannot see how it cannot. Those measures need to be agreed upon nationally, so the various jurisdictions throughout Australia can then enact those measures through their state government policies and have links. There needs to be those measurable outcomes on both sides of the fence—not just for the provider but also within policy and decision-making frameworks.

ACTING CHAIR: We have identified that children, adults and the elderly have to be catered for differently with respect to their care needs. Is there a link between children at a younger age—and Senator Williams was referring to those up to three years old being key—and either one or both of their parents having mental health issues? Is it a flow-on issue through to the children? Is there a way we can intercept that?

Prof. Littlefield : There are lots of factors that can contribute to someone having a mental health problem. Certainly there are genetic factors that flow down through families, but equally strong are the behavioural factors of parents around parenting and the way they bring up the children. There are social factors to do with the situation in which they live—poverty, no house or whatever. Factors such as family conflict and violence are the big social issues. So it is actually multifactorial. You could draw a diagram with all these factors and we really need to intervene at all levels. Not all things are fixable, but we could do a lot better than we do now.

Mrs Hand : One of the things that really stands out for me is that no-one chooses a mental illness. I think that parents who have symptoms of a mental illness and are managing as parents do the best that they possibly can with what they have at the time. If you have bipolar and you have to get up at 6.30, look after your child, take them to school and stick to a routine and you have a mood disorder that prevents you from leaving the house, that is when the supports need to come into play to support those parents so that they can be good parents. It is not their fault that they have a mental illness. It is a symptom of the illness that they have. We as a society and a community need to wrap around those people so that they do not feel failures as parents and they do not give up and start behaving in a way where they isolate themselves. They are the people who need to connect to get those supports.

ACTING CHAIR: Beautifully said.

Mr Bewert : Again from a Salvation Army perspective, we run multiple programs right across the Australian public. To support Professor Littlefield's comment that it is multifactorial: the Salvation Army is first and foremost a church and there would not be one core ordained Salvation Army officer who would not encounter these issues in their local core environments within their local community in dealing with local families. The issues of poverty, the social demographic, education and learned behaviours from family situations that have been passed on generation to generation all have an impact on a child's sphere of reality, and I think that is something that needs to be considered.

Senator McLUCAS: Can I just contextualise this a little bit. First of all, I want to pass on the apologies of our chair, who is really sick—she has some sort of tummy bug. She is very disappointed she could not be here. In saying so, Senator Muir is doing a fine job of chairing this meeting.

Senator WILLIAMS: Who said that?

Senator McLUCAS: I did and you seconded it, if I remember!

Senator WILLIAMS: I second it, Senator McLucas! He is doing a fine job.

Senator McLUCAS: The Senate Select Committee on Health has decided to focus on mental health in a three-day inquiry—today, on Friday in Sydney and then later on 18 September in Brisbane—because we felt we needed to tease out some of the recommendations in the Mental Health Commission's report, provide a greater community conversation about those recommendations and hopefully even get some of our friends in the media to think a bit more about mental health, which would be a nice thing to do. So are you listening? One of the recommendations which I think has a bit of relevance to this group here is the recommendation that the commission have made around suicide. They have made a recommendation that we need to trial suicide prevention in 12 distinct areas around the country—like their recommendation about primary and mental health networks, we need to regionalise the services. I dare say a lot of you would have had some visibility of that recommendation and might like to talk to us about how you think that would work, and make some recommendations to our committee about that. A few of you are closely engaged in suicide prevention.

Mr John : I might start, if I may. The National StandBy Response Service is actually only in limited communities in the environment. Probably one of the most difficult challenges of expanding the service to those 16 communities is talking to the communities in which we have not been able to allocate the service. United Synergies had the difficulty of actually making decisions around that in that space. I understand that we are limited and we have to do some trials and we have to do that in that space.

This probably comes to the context of the discussion around where our priorities sit as well. Suicide is the leading cause of death for anyone under 44 in our community. If we want to make a difference we have to have a different approach around that. We did it 25 years ago with road deaths, and I am very thankful about that because I think there are a lot of people still living today as a result of a whole range of changes. It involved a large number of communities, non-communities, businesses, legislation, police and engineers—including car manufacturers—to actually make differences in that area of road deaths.

The National Coalition for Suicide Prevention, which is a collaboration of 28 different organisations with many other contributors in different reference groups around that—many around the table here are involved in that process as well—have come together to make a decision about a commitment over the next decade to reduce or to halve the number of suicides in Australia. That will involve not just a collaborative approach with mental health service providers, financial counsellors, emergency counsellors, police and ambulance but a whole-of-community discussion around this and how we actually do that differently. The coalition wants to see how this responds differently. I think the logical approach is to think about that in a 12-site approach. Our personal opinion is that that does need to be done with a level of cohesion between services in those regions. United Synergies has chosen a strategic approach to look at finding the local organisations who can deliver that model for the community. We are not replicating a whole range of circumstances around that; we are actually building on the local networks around that.

To explain a bit of the attributes of what we look for in a site to deliver that: we currently deliver the StandBy Response Service with partners from Lifeline, Anglicare, Centacare, UnitingCare, Mates in Construction, local small organisations, health development boards and the local community. There is no one uniform brand of an organisation. We look for certain attributes in a community organisation that will actually be able to be a point of contact for those areas. What I am trying to get to is that there are levels of specialty in delivering services that need certain attributes. That needs to be found in a local community and needs to be coordinated with the local partners around that community.

Coming back to Jack's comment about where innovation and service improvements happen, there is good evidence and there are good ways in which things develop, but it comes down to the implementation. I think that is really what this 12-site recommendation is about: 'Let's trial it in 12 sites.'

Senator McLUCAS: I think they are calling it staged implementation rather than trial.

Mr John : Okay, staged implementation. The other question is: how do you make the decision about which 12 sites are in that space? There are a whole range of concerns around that. Suicide also has a psychological effect, and I think the question that is probably pertinent there is: how much do we value communities and the support around our communities? Going to 12 sites is probably economical and rational, but I think we also need to think about the impact of exclusion of different communities from available resources in that space.

My final comment would be about linking up with where there are some primary health front-line services around mental health through the states, the Primary Health Networks and the better access program. There needs to be some better coordination of the access to those services and how they are distributed as well.

Senator McLUCAS: And that is outside of the suicide prevention approach? That is more in the primary and mental health?

Mr John : Yes, available resources for ongoing support.

Prof. Proudfoot : In putting together the proposed framework of suicide prevention, we—that is, the Centre of Research Excellence in Suicide Prevention, CRESP—did a lot of consultation with police, ambulance, justice et cetera and talked about this implementation at the local level. There is a great deal of enthusiasm and commitment to it. In particular, there is recognition that we need to use evidence based strategies. Some of them are more effective than others, but in other regions strategies are being used that may seem to make sense but are not necessarily evidence based. So we need to stick with the evidence based strategies but also go in, have a look at what is available at the local level and what is needed at the local level as well, and really build on that. We are talking about local organisations too—banks et cetera. There was enormous commitment. It was very heartening to see that. There was a recognition that it would not be easy but that nevertheless this must be the way we go.

Mr Dalgleish : I would like to add that I think that local and regional coordination efforts and face-to-face services can also be supported by telephone and online counselling agencies. We have the capability to provide 24/7 support to back up local services. Also, as we have heard around the table, I think online applications in relation to depression, anxiety and other issues can be integrated into that service delivery.

Prof. Littlefield : I would just like to say that I hope that as part of these trials some extra training and effort would be put into risk assessment to actually stop the suicide from occurring, because there is quite a bit of data about people presenting—not usually saying, 'I'm suicidal,' but with some other problem—to a service or a professional in the month or two before they actually do it. So I think we should look at prevention as part of the trial and skilling up people to do risk assessment if they suspect that is the case.

Prof. Proudfoot : We would also recommend gatekeeper training and also front-line staff training and so forth.

Prof. Littlefield : Yes, that sort of thing.

Prof. Proudfoot : So assessment not just by health professionals but by anyone—schools et cetera.

Prof. Kyrios : Absolutely.

Prof. Proudfoot : These are some of the nine approaches that have been found to be highly effective.

Mr Heath : CRESP does great work in going to particular regions. We need to get a better understanding of what is happening in a particular community with suicide rates going down or not. There are nine different elements to the CRESP proposal, of which some operate at a national level like crisis help lines. If you go into a small country and you have a son with schizophrenia, the first place you will probably go is online or pick up the phone to speak to someone. It is about having the right mix. Across the board people are supportive of these things being done in regions. From a SANE perspective, we would probably say that you would want to look at those regions where there is strong local leadership that is wanting to bring this stuff forward. We heard yesterday that in Mount Druitt there are 57 different government programs because there is a high need. You need to go where there is strong leadership. I will leave it there.

Senator McLUCAS: Can we talk more about this emerging e-mental health work. It seems to be growing like topsy. How do you tell a lay person like me that I should feel comfortable about the quality of the work that is being developed? I would also like to have a better understanding of the pathway. We are told that boys between the ages of 17 and 25 access their e-mental health between eleven o'clock and one o'clock in the morning. Doctors are not available then. So tell us about the pathway and the quality assurance we should be aware of.

Prof. Proudfoot : They are really important questions. The Department of Health did have an expert advisory committee some time back. When we brought all of the e-mental health providers together last year to develop a series of recommendations, one of those recommendations was that an advisory committee be re-established. It did some very important work. One piece of work it did was to establish a portal that people can access, and all of the programs on that portal are secure and evidence based. That is mindhealthconnect. Beacon is a slightly different portal which looks at the evidence, and that is run by the ANU. There are definitely opportunities there for people; there are so many programs out there, but not all of them are good or evidence based.

We also acknowledge that there needs to be a number of pathways into e-mental health. It does have enormous potential, but in Australia we are not using the potential effectively. We know that the programs which have been evaluated are clinically effective and cost effective. E-mental health should not be available only through general practice, though we do recognise that should be improved, because many young men, for example, do not visit a GP. Social media is one way through, but we need to educate and raise awareness in the community that (a) these programs exist and that (b) there are many which are evidence based and they are the ones that people should be using and this is how to get into using them.

Prof. Kyrios : I would like to add to that. I think it needs to be integrated within a staged-care or stepped-care kind of model. There are self-help options and therapist assisted options, and both are effective for different populations. If you have a moderate or severe disorder, then clearly therapist assisted is the better option—they are also cost effective and also more effective. You need to integrate it within the profession. We as psychologists have really been at the forefront of the development of these, and yet very few of our own people use them in their own clinical practice. I think we need to look at our own training models.

I certainly agree with the higher use of social media to promote these. In fact, we have just finished a randomised controlled trial of treatment for OCD, and we got most of our people through social media. It was very effective. These are new referral pathways. But I think we also have to use the traditional referral pathways. GPs need to be able to say to someone: 'Here's a token. Go and use this and see how it works and then come back and tell me. If it hasn't worked then we'll try something else.' This needs to be targeted for appropriate populations. You would not do it for someone who is too severe.

Prof. Proudfoot : One of the other things that the expert advisory group in e-mental health did—and this has been in effect for about 18 months now—was to establish training for general practitioners, and Black Dog is doing that; for allied health practitioners, and ANU is conducting that; and for Aboriginal and Indigenous mental health workers. University of Sydney and Menzies are running that. So there is a recognition—going to Mike's point—that we do need to raise awareness of mental health professionals as well.

Prof. Kyrios : We do have a problem. The review has recommended that we bring commercial partners into this. I think it is imperative that we do, because the bodies that have been funded by the federal government have kind of niche interests and may not have the infrastructure to roll out these programs nationally. There certainly needs to be greater integration. I think that that element of it is actually missing. How do we take what we actually have—which the federal government has already paid for, which is evidence based, which is world's best practice—from these six, seven or eight little groups within various universities to rolling it out nationally? When we do that with commercial partners, how do we make sure that the research-and-development aspect of it is maintained at the level that it is currently working? I think that is a real risk. Commercial entities will not be interested in the research and development in the same way as the researchers are.

Prof. Proudfoot : I do not think we would let them get away with that.

Prof. Kyrios : It is a risk, though, and I just wanted to put that on record.

Ms Adams : I just want to make the point—and perhaps reinforce before—about the risk identification. When we introduced online counselling in 2001, for the Kids Helpline, we introduced it with our clinical team as part of that process. They developed the self-help tools that we have on that website, and we get more than 500,000 young people using those self-help pages. But the online counselling component must maintain the same robustness as any other of the counselling interventions that we have. I think one of the big things that the community has to come to terms with is: who is reputable; where does the trust come from; how do we maintain quality; and how do we make sure that those risk factors are considered when a person is choosing to engage online? Some of the other tools that practitioners can use are not available in the online medium, such as voice identification, or stressors and these sorts of things, so I think there is a need to be very robust in the practice measures as we develop more and more online tools and not lose them in the context of wanting to roll out more and more. I think it is ensuring we have got a balance of quality as well as access, because we need to provide services that add value to the people who want them, not the other way round. It is always a balance to consider.

Mrs Rosenthal : I was just going to make the point that the Salvation Army looks after society's most vulnerable and we always have. I support the development of e-health, but I think we need to recognise that not everybody has access to e-health. Too much of a focus on e-mental health is not going to work for your average homeless person or your average person with a culturally and linguistically diverse background. The other comment that I would make around e-health—and we have come across this as a provider—is that access to reliable networks, in terms of access to the internet, is not always available in our rural and remote locations. It is all very well to have a fantastic app for mindfulness or whatever, but, if you cannot connect, you cannot do it. I think that point needs to be made.

Senator McLUCAS: Good point.

Mr Heath : I absolutely agree in terms of the areas where there is access, but I started work in this area around the internet and youth suicide 20 years ago and, at that stage, maybe three or four per cent of people had access to the internet, and people were saying, 'Don't waste your time doing this.' Now your coverage rate is 90 per cent or whatever. There is the fantastic work Black Dog has been doing for many years around this. When it comes to e-mental health, I believe that Australia may well be there already. It has the capacity to lead the world in this area. We have the world's leading technology companies coming to Australia to test new products and services. We are only 23 million people. We are very technology literate. If you wanted to pick an area where substantial investment by government could have huge returns, I think it is in the e-mental health space, whether it is the work that Young and Well CRC is doing or ReachOut and all that. Also, in terms of usage rates, you will find that pick-up rates of technology by Indigenous communities are as high as they are for the general population.

Senator McLUCAS: Yes, they just jump at technology.

Prof. Kyrios : Yes.

Mr Heath : It is not the answer to everything, and we still need to provide for those people who are very vulnerable and do not have access, but there is a huge opportunity here, because so many groups in Australia are doing phenomenal work. I spent two years working in the States. We are not very good here at celebrating the great things that we are doing. I was staggered by how highly Australia is regarded on mental health and e-mental health in the United States and in other countries. So I think this is an area of huge opportunity, and we need to be celebrating the great work Black Dog and others are doing in this area, because there is an opportunity, when we have a population of 23 million that is pretty well wired and is going to be better wired under the NBN, to do stuff that is going to make a huge difference right across the community.

ACTING CHAIR: That goes hand in hand with what you were saying in relation to ice earlier on, doesn't it? We should perhaps be promoting things in a different way from how we do.

Mr Heath : Yes. The thing that motivates me is when I get a sense that you understand what I am going through and there is a real empathy, and you are creating a sense of hope that there is a possibility of something beyond my immediate situation. So the role-modelling or the success examples are the things that cause a person to say: 'You know what? I might be homeless and destitute, but there's someone like me who's been able to get to a better place.' We need to celebrate that, because that is what motivates people and lifts their gaze. If we keep talking about the problems and the numbers and all that, we just go in, in, in. So we need to celebrate those achievements, and that is the thing that actually elevates things for people.

Prof. Kyrios : Can I add just add that a lot of the e-therapy programs have patient stories or personal stories of recovery using actual patients, actors or whatever, and I think they make a huge difference in terms of engagement. The more sophisticated our programs become, the more likely people are to engage and finish the treatment successfully.

Senator McLUCAS: I was going to talk some more about NDIS transition, but I think you have covered the issues with PHaMs and Partners in Recovery. I think we have made those points strongly.

Mrs Rosenthal : Can I just make a very brief point—not in relation to the NDIS but on the introduction of the Commonwealth Home Support Program. We run a carer counselling, information and support service in Queensland which supports carers of older people and people with disabilities—often people who have mental health problems. Under the new Commonwealth Home Support Program, that program does not fit. So we do not see a commitment from government to the ongoing support and funding of those services.

Senator McLUCAS: It does not fit because?

Mr Bewert : There are multiple other providers who also run a very similar service, and they are expressing the same concerns on the consultation periods with CHSP. In terms of it not fitting, the guidelines that have been set for the new Commonwealth Home Support Program do not include within their scope programs such as that.

Mrs Rosenthal : It is missing.

Mr Bewert : Again, our colleagues at PHaMs said, 'We're very concerned about these people falling through the gaps.'

ACTING CHAIR: On that note, I would like to thank all our witnesses for their valuable contribution.

Senator McLUCAS: I too thank you all very much for your contribution to this inquiry.

Proceedings suspended from 15:34 to 15:49