Inquiring about mental health

October has shone a spotlight on mental health at both the state and national level. First, the federal government announced a Productivity Commission inquiry into the role of mental health in the Australian economy and the best ways to support national mental wellbeing. A fortnight later, the Victorian Premier promised a royal commission into mental health if re-elected.

One in five Australians will experience mental illness in any one year and almost half of the population will experience mental ill-health during their life time. The demand for services is soaring. In Victoria alone, the number of people presenting at Victorian emergency departments with mental health crises increased by 19 per cent over a four period to mid-2017.

While the imperative for accessible mental services that improve the lives of people is unambiguous, the pathway to reform is complex and littered with past reviews and reports. This includes KPMG’s and Mental Health Australia’s 2018 Investing to Save report and the National Mental Health Commission’s 2014 review of mental health programs and services commissioned by the federal government. There is no shortage of robust, expert advice to steer future directions and solutions.

A national inquiry

The Production Commission inquiry was announced soon after the release of Australian Bureau of Statistics data which showed suicide rates are at a 10-year high with 3128 lives lost in 2017, a jump of 9.1 per cent from the previous year. The cost of mental illness in Australia is around 4 per cent of GDP and the federal government spends around $4.7 billion per year on mental health. If you add state and territory funding, the annual spend rises to $9 million, less than 1 per cent of GDP.

It is questionable whether this funding is producing the best outcomes with more lives being lost now than 10 years ago. The Productivity Commission will most likely scrutinise mental health funding as well as recommend key priorities for the government's long-term mental health strategy. The inquiry will begin this year and the final report is expected to be handed down in 18 months.

The Victorian election commitment

The promised Victorian royal commission into mental health replicates the 2014 pledge from then opposition leader, Daniel Andrews, to hold a royal commission into family violence if elected to government. In a move straight from the same playbook, the Premier has committed to establishing the mental health royal commission within 100 days of re-election and implementing all recommendations without consideration of cost or feasibility.

A royal commission has a symbolic significance, signalling the gravity of the issue and the seriousness with which it’s being treated. Family violence was declared a ‘national emergency’ in 2014 and mental health was described in identical terms a few weeks ago.  However unlike family violence, the mental health emergency has happened on this government’s watch. Is the Premier’s announcement of a royal commission an admission of policy failure and under investment over the government’s four year term?

This includes the record investment of $705 million allocated in the 2018 Victorian budget and the much vaunted 10-year mental health plan released in 2015. This plan set out a long term reform agenda which sought to guide investment and drive better mental health outcomes for Victorians. Over 1000 people contributed to the plan’s development including people with a mental illness, their families and carers, service providers, clinicians, workers, experts and community members. Was it a missed opportunity for systemic reform or was it a case of inadequate funding accompanying the plan?

If the Andrews government is re-elected, the royal commission will be tasked with providing recommendations on how Victoria’s system can best support people experiencing mental illness. While the timeframe for reporting has not been announced, it begs the question: what happens to the mental health system in the interim? Do the policy initiatives under the 10 year plan continue? Is any future investment put on hold or is it piece meal fixes until the report is handed down? And how does the royal commission sit alongside the Productivity Commission inquiry which will have commenced by the time the royal commission is established.

An issue of governance

While the names of the commissioners will be announced within 100 days of re-election, the Premier has taken the unusual step of announcing the chair of an expert advisory committee to the mental health royal commission. While Patrick McGorry, a Professor of Youth Mental Health at the University of Melbourne, is eminently qualified to hold the role, it is the expert advisory committee which is unusual.

In the last 20 years, there have been four Victorian royal commissions: the Esso Longford gas plant accident; metropolitan ambulance service; 2009 bushfires; and family violence. Led by independent commissioners appointed on government’s recommendation, they did not involve the use of an expert advisory committee. This is not to say that experts were excluded from these royal commissions. They contributed to the commission proceedings through briefings, commissioned research, submissions and round table discussions.  But they did not have a formal role in the royal commission’s deliberations. How the governance relationship between the expert committee and the commissioners is managed will be something to watch if the government is re-elected.

Complex intergovernmental arrangements

In announcing the royal commission, the Premier asked, ‘How do we build Australia’s best mental health system?’. Any solution will require the involvement of the federal government given the complex intergovernmental arrangements in mental health. Both levels of government share responsibility for mental health policy as well as providing mental health services.

With family violence, the Victorian government had sole jurisdiction over the key policy and service delivery areas such as police, courts, child protection, corrections and the funding of specialist family service providers. This is not the case with mental health. The state funds and delivers public sector mental health services such as the care provided in public hospitals as well as community based services and a range of prevention and early intervention initiatives. The federal government funds mental health-related services through the Medicare Benefits Schedule (eg GP visits) and also subsidises private hospitals, psychiatric and psychological services. It is also actively involved in promotion and prevention which is one of the key aims of the National Mental Health Strategy.

Genuine reform of the mental health system means taking a whole-of-government perspective at all levels. The Productivity Commission will have to address this in its inquiry as will the royal commission if it proceeds.

Valuing the lived experience

Even if the Productivity Commission and the royal commission go down separate paths, they must be in absolute lockstep when it comes to involving people with the lived experience of mental illness. The value of the lived experience has long been recognised by the mental health sector. It is seen as fundamental to designing and implementing mental health services and central to improving the lives of people with mental illness.

For the Productivity Commission and the royal commission, this involvement must extend beyond the usual consultation and engagement processes to participation that contributes to decision-making. Imagine the powerful signal the Premier could have sent had he announced a co-chair with lived experience alongside Patrick McGorry. Imagine the insights a person with lived experience could bring to the Productivity Commission inquiry if they were part of the secretariat.

Only by bringing together the lived experience with expert knowledge can we truly achieve reforms that puts people at the centre of the mental health system.