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Our 2013 recommendations

In 2012 we made ten recommendations for action. Since then 3.2 million Australians have experienced a mental health problem and at least another 2,200 people have died by suicide.

So these recommendations remain just as valid this year as they were last year. We re-state them here.

In 2013 we add a further eight for action.

We will re-visit all recommendations every year until we have evidence of change that can be seen in the lives of people living with mental health problems and their supporters.

Our recommendations are stepping stones towards a vision that all people in Australia achieve the best possible mental health and wellbeing.

We want to see healthier people, fewer people institutionalised in our prisons, less disadvantage and stronger Aboriginal and Torres Strait Islander communities. We want our young people to have a contributing future; families to thrive; a society that does not discriminate on the grounds of mental illness, race, disability or sexual preference. We want strong resilient mentally healthy communities, schools and workplaces.

Next year we hope we can give a positive report back on how these recommendations were addressed by us, our governments and service and support providers.


2012 Recommendations

Recommendation 1

Nothing about us, without us – there must be a regular independent survey of people's experiences of and access to all mental health services to drive real improvement.

Action: The National Mental Health Commission will undertake a regular national survey of people with mental health difficulties and their families and support people. This survey will consider access to services, as well as perceptions and experiences. This will build on and complement existing efforts and ensure that people always have a voice and remain at the centre of decision-making about all the services that impact on them.

Recommendation 2

Increase access to timely and appropriate mental health services and support from 6-8 per cent to 12 per cent of the Australian population.

Action: All governments must agree and meet the target in the Fourth National Mental Health Plan Measurement Strategy that 12 per cent of the population should be able to access mental health services in a year. There must be an agreement to this indicator with an implementation plan and investment strategy to achieve this.

Recommendation 3

Reduce the use of involuntary practices and work to eliminate seclusion and restraint.

Action: All jurisdictions must contribute to a national data collection to provide comparison across states and territories, with public reporting on all involuntary treatments, seclusions and restraints each year from 2013. This information should be reported at the service unit level.

Action: The National Mental Health Commission will call for evidence of best practice in reducing and eliminating seclusion and restraint and help identify good practice treatment approaches. We will do this in partnership with the Mental Health Commission of Canada and Australian partners, including the Safety and Quality Partnership Standing Committee, Disability Discrimination Commissioner, Australian Human Rights Commission and interested state mental health commissions.

Recommendation 4

All governments must set targets and work together to reduce early death and improve the physical health of people with mental illness.

Action: Enduring mental illness must be given the status of a chronic disease to give it higher national focus and support.

Action: The physical health needs of people with mental health problems need to be given a higher priority in all areas of health. The initial focus must be on rapidly reducing cardiovascular disease by reducing risk factors such as smoking and poor diet, and by increasing physical activity for people living with mental health problems.

Action: All government-funded mental health related programs must also be measured on how they support people to achieve better physical health and longer lives. Priority should be given to the financing of multi-disciplinary primary care (through GPs and other primary health care organisations).

Action: All relevant services must give priority to tracking of both the physical and mental health needs of those with enduring mental illness.

Recommendation 5

Include the mental health of Aboriginal and Torres Strait Islander peoples in 'Closing the Gap' targets to reduce early deaths and improve wellbeing.

Action: Mental health must be included as an additional target in the COAG 'Closing the Gap' program. This must be done through the development and implementation of an Aboriginal and Torres Strait Islander Mental and Social and Emotional Wellbeing Plan to commence in 2013. This must also address the future findings of the Aboriginal and Torres Strait Islander Suicide Prevention Advisory Group.

Action: Training and employment of Aboriginal and Torres Strait Islander peoples in mental health services must increase. There must also be better support for Aboriginal and Torres Strait Islander families. There must be regular reporting on progress.

Recommendation 6

There must be the same national commitment to safety and quality of care for mental health services as there is for general health services.

Action: All governments must agree that there is the same emphasis on improving the quality of care and reducing adverse events in mental health services as applies to other physical health services. Governments must commit to implement nationally agreed and mandatory service standards in mental health services as they have for other health services. The National Mental Health Commission will work with the Australian Commission on Safety and Quality in Health Care to identify what it takes to get proper uptake of national mental health service standards and make them mandatory.

Recommendation 7

Invest in healthy families and communities to increase resilience and reduce the longer-term need for crisis services.

Action: Increase enhanced and personalised support for parenting through culturally relevant forms of home based visiting (ante-natal and in the first few years of life). These must be provided at a local or regional level. There must also be active follow-up where a family is under stress or experiencing tough financial or social difficulties.

Recommendation 8

Increase the levels of participation of people with mental health difficulties in employment in Australia to match best international levels.

Action: The National Mental Health Commission will pull together a taskforce including industry, government and community leaders, to actively promote effective government and workplace programs that increase the participation of people with mental health difficulties in employment. The Commission will partner with key industry and community groups to Call for Evidence and work together to advance the adoption of good practice in Australia.

Action: Employment support programs, initiatives and benefits must be more flexible. They must recognise that mental illness comes and goes — and what that means for people and their families. Programs must provide long-term support for the employee, families and support people and the employer, with appropriate incentives and milestones.

Recommendation 9

No-one should be discharged from hospitals, custodial care, mental health or drug and alcohol related treatment services into homelessness. Access to stable and safe places to live must increase.

Action: All governments implement and report regularly on the existing COAG commitment of 'no exits into homelessness' from statutory, custodial care and hospital, mental health and drug and alcohol services for those at risk of homelessness.

Action: Discharge planning must consider whether someone has a safe and stable place to live. Data must also be collected on housing status at point of discharge and reported on three months later, linked to the discharge plan.

Action: Governments must commit to removing any structural discrimination barriers to accessing housing. Just as important is providing support to help vulnerable residents to settle in, adjust and remain in their homes.

Recommendation 10

Prevent and reduce suicides, and support those who attempt suicide through timely local responses and reporting.

Action: Develop local, integrated and more timely suicide and at-risk reporting and responses. Developing and rolling out well co-ordinated community-based, culturally appropriate, early response systems and suicide prevention programs which promote community safety, reach the most vulnerable, and using up-to-date information from the 'first responders' such as police officers, occupational health workers, ambulance officers and mental health workers.

And in 2013 we add a further action...

Action: Programs with a proven track record (which are evidence-based) must be supported and implemented as a priority in regions and communities with the highest suicide or attempted suicide rates – action needs commitment and a humane approach.


2013 Recommendations

Recommendation 11:

People with co-existing mental health difficulties and substance use problems must be offered appropriate and closely co- ordinated assessment, response and follow-up for their problems.

Co-existing mental illness and substance misuse

People who experience co-existing mental health difficulties and substance misuse can live contributing lives if they are able to access appropriate services and support for both issues. These people are too often discriminated against and treated as though they are less worthy of help. Their needs must be responded to in a comprehensive, integrated way wherever they present. Workers on the ground are often not supported to work in this way. That may be because of siloed structures, inadequate funding or constraints on professional development and supervision.

Action: We must have a mechanism to test compliance with 'No Wrong Door' practices and ensure they do not exclude or discriminate against people with co-existing mental health and substance misuse problems. The benchmark for this must come from the experience of people affected by these difficulties, their families and supporters. Then we can start to measure uptake of policies and impacts on peoples' experiences.

Action: The Commission calls for innovative responses in this area that do not discriminate against people with co-existing difficulties – particularly around integrated services, funding and policy. These must embed appropriate assessment, treatment and professional supervision and be systematically evaluated. This will expand our understanding about what works, and help develop more effective models of practice appropriate to different groups.

Action: Funding must facilitate these actions, not create barriers to them.

Recommendation 12:

National, systematic and adequately funded early intervention approaches must remain. This must be accompanied by robust evaluation to support investment decisions, with a focus on implementation, outcomes and accountability.

Early Intervention

We support early intervention and acknowledge the significant recent investment in these initiatives for young people. It is important that these services are given enough time to bed in. We need to build in robust evaluation with outcome measures and accountability of these services to young people and their families and supporters. The concept of early intervention for people at any age or stage of life should remain a high priority.

Action: People using services, their families and supporters must be engaged with co-design, evaluation and monitoring of early intervention initiatives.

Action: Continuous practice improvement must be driven by the findings of ongoing independent rigorous evaluation and appropriate accountability.

Recommendation 13:

A National Mental Health Peer Workforce Development Framework must be created and implemented in all treatment and support settings. Progress must be measured against a national target for the employment and development of the peer workforce.

Peer workforce

Delivering recovery-focused services must involve growing and properly supporting our peer workforce. Without exception, the peer workforce includes both people with lived experience and personal carers. To do this, we need clear employment provisions and working conditions, training opportunities, professional capabilities and workforce development strategies, including supervision and mentoring requirements. All must be standardised nationally.

Action: All governments and agencies must work together and with suitably experienced people with lived experience and their families to agree and implement a National Mental Health Peer Workforce Development Framework.

Action: This framework must identify a target and implementation strategy for the employment of peer workers in all support and treatment settings.

Action: The Certificate IV Peer Work training materials developed by Community Mental Health Australia must be rolled out nationally when available.

Recommendation 14:

A practical guide for the inclusion of families and support people in services must be developed and implemented, and this must include consideration of the services and supports that they need to be sustained in their role.

Including families and support people

People with lived experience of mental health issues, either personally or as a support person, tell us that the most important enabler to a contributing life is strong and supportive relationships and connections. However, what we have heard is that families and support people, when coming into contact with services, are too often excluded and perceived as irrelevant.

Action: Effective approaches to the meaningful inclusion of families and informal support people exist, and these must be harnessed and incorporated into a national practical guide.

Action: The Commission will use the Contributing Life survey to assess compliance with these principles. This will complement the work being developed on the Consumer and Carer Experience of Care tool.

Recommendation 15:

The Commission calls for the implementation and ongoing evaluation of a sustained, multi-faceted national strategy for reducing discrimination.

This should encourage positive and affirmative action by every person, family, service, school, workplace and community to help others to live a contributing life. It must be centred on community-level initiatives, and be targeted at areas and groups most resistant to change and where there is the most potential to bring about improvement, consistent with the evidence.

Community understanding

While concerted efforts mean that Australians are becoming more aware of and talking more about mental health and suicide, the Commission continues to hear about individual and systemic discrimination and misunderstanding. In particular, people living with certain illnesses, such as psychoses, continue to face entrenched discrimination, which only adds to their marginalisation.

Action: We will continue to work with others to consider ways to end the vilification of people with mental illness.

Action: We need more targeted anti- discrimination initiatives, beginning with those who come into frequent contact with people with mental health problems and their families and support people, as well as those among whom discrimination is the greatest.

Recommendation 16:

All Australians need access to alternative (and innovative) pathways through school, tertiary and vocational education and training.

There are already many good examples of these which must be recognised, valued and scaled up. This is crucial to engaging people who are disconnected and for whom 'mainstream' institutional structures form barriers to a contributing life.

Transitions through education

All transitions and changes can be challenging, but particularly so for people living with mental health problems. Our years in kindergarten, school, vocational college, TAFE, apprenticeships and university see some of life's biggest transition points. Our education and training systems know this and support us through these. However, people with mental health difficulties may need additional support and more innovative pathways so they keep connected.

Transitions and changes occurring in education and training must not leave people with mental illness behind, but rather create opportunities to keep them engaged in education, employment or training to live productive and contributing lives. This is especially important for young people living with mental illness, from disadvantaged backgrounds, those who live in rural and remote areas, and Aboriginal and Torres Strait Islander peoples.

Action: Australian governments must collect data, and report nationally on the educational participation of people experiencing mental health difficulties. A target must be set to reduce the numbers of those with mental health problems falling into the “not in education, employment or training” (NEET) group, thus tracking our progress against that of other countries.

Recommendation 17:

Where people with mental health difficulties, their families and supporters come into contact with the justice system and forensic services, practices which promote a rights and recovery focus and which will reduce recidivism must be supported and expanded.

These include:

  • diversion services to create pathways for people with mental health problems away from prison and into support and treatment;
  • justice reinvestment for Aboriginal and Torres Strait Islander peoples and people with mental health issues who are in contact with the justice system; and
  • arrangements that give better rights protection, supported transitions and follow- up for people with mental health issues in custody, prison and forensic facilities when they are released or discharged. These must include step-down forensic services and supported community accommodation.

The justice system and mental health

The Commission knows of examples of contact with the criminal justice system and diversion schemes being an opportunity for people with a mental health problem to start on the path to a contributing life. All too often, however, this contact is not only damaging to their mental health but also to whole-of-life outcomes.

People who experience mental health problems who are in contact with any part of the criminal justice system and their families and support people need approaches which support their mental health needs and improve personal outcomes, and which also reduce recidivism rates.

The Commission finds that there are strong human rights, health and economic arguments to address these failings. It is in the community's interest for the criminal justice system to respond appropriately to mental health issues while a person is in corrections services, to prepare them to rejoin the community and to follow up with them on their release. The criminal justice system should not create or contribute to further mental health problems, and must provide opportunities for assessing and addressing mental health issues.

Action: State and territory governments must scale up diversion schemes, justice reinvestment, and transition support.

Action: State and territory governments must provide better mental health programs to those who come into contact with the justice system, so that people have their mental health improved rather than diminished.

Recommendation 18:

Governments must sign up to national targets to reduce suicide and suicide attempts and make a plan to reach them. These targets must be based on detailed modelling.

Suicide prevention

It is unacceptable that at least 2,200 lives are lost to suicide in Australia each year. Suicide affects young people disproportionately and as a result is a leading cause of healthy life years lost in our country. It compounds and reflects existing patterns of disadvantage in Australian society.

In addition, there were an estimated 65,300 suicide attempts in 2007 reported by the Australian Bureau of Statistics. The biggest risk factor for suicide is a previous suicide attempt. We have limited understanding of what people experience leading up to and after a suicide attempt.

An internationally tried and tested way to focus minds and encourage co-operation and action is to introduce a national target for a reduction in the suicide rate. The COAG Expert Reference Group on mental health reform has proposed a reduction in the national suicide rate by 10 per cent in four years and 50 per cent in ten years.

The Commission supports this ambitious goal.

This Report Card shows how little we know about what works to bring population suicide rates down. Practical and detailed implementation plans are required to realise this ambition.

To give further impetus to the implementation of last year's Recommendation 10, we recommend that:

Action: Programs with a proven track record (which are evidence-based) must be supported and implemented as a priority in regions and communities with the highest suicide or attempted suicide rates – action needs commitment and a humane approach.

Action: This modelling must:

  • incorporate the best current evidence from Australia and proposals for small-scale piloting of approaches with promising evidence. It should identify where targeted research is most needed;
  • identify proposals for how practical collaboration can be fostered – as the basis for a systemic approach to suicide prevention. This applies not just across government departments and between federal and state governments. It also means collaboration at a local level between providers of health, welfare, employment, education, housing, legal and justice sectors, and also between providers and users of services and supports; and
  • determine priorities for investment. We know little about the cost-effectiveness of suicide prevention approaches, and we need to start by undertaking robust evaluation of existing initiatives.

Action: Existing community-based suicide bereavement support activities for families and support people must be scaled up and new ones encouraged – particularly in Aboriginal and Torres Strait Islander communities.

Action: Australia needs a national picture of the contributing factors to suicide attempts, starting with those most at risk, so we can work out sensitive responses to those groups, marshal resources and, over time, measure our success.

It is vital to hear from those who have survived a suicide attempt and from their families and supporters about what helped and what made things worse at the time. To contribute to this effort, the Commission has initiated a small study by the Centre for Research Excellence in Suicide Prevention into peoples' experiences leading up to and following a suicide attempt. 

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