VCOSS Submission to Issues Paper into the Social and Economic Benefits of Improving Mental Health

Introduction

Mental illness can affect a person’s ability to participate in work, education, community life, to secure housing and build strong relationships. At a societal level, it influences productivity and earning potential, innovation, social cohesion and connectivity. It has been estimated that mental illness costs the Australian economy up to $60 billion per year.[1]

Despite this, the mental health system remains chronically underfunded. Victoria now has the lowest per capita spending on mental health services in the country.[2] The Victorian Government’s recent establishment of a Royal Commission into Mental Health (Commission) is indicative of a system in crisis.[3]

But the Commission has rightly recognised that in many cases the answers lay beyond the clinical mental health system. To build a mentally healthy community, we need to address the reasons why people become unwell, intervene early when they are at risk, and invest in strategies that promote good mental health. It is critical that the Commission investigate the role that promotion and prevention can play in improving mental health within the community.

People experiencing disadvantage are more likely to have poor mental health. In this submission, VCOSS adopts a social determinants of mental health framework to recommend strategies that could improve mental health. Mental health is viewed over a life course, taking specific influences into consideration, such as identity, geographic location and socio-economic status.

Poverty, homelessness, drug and alcohol use, and histories of abuse and trauma all contribute to a person’s mental health. We cannot hope to reduce the rates and burden of mental illness without considering policy responses that address these issues as well.

The Commission must also prioritise the voices of people with lived experience of mental illness. They are well placed to provide high quality advice on how they should be supported.

VCOSS welcomes the wide scope of the Commission’s inquiry, and urges the Commission to maintain its focus on broader reforms outside healthcare – in workplaces, education, justice, housing and social service systems.

 

Recommendations

Adopt a social determinants approach

1. Adopt a social determinants approach that examines mental health over the life course, and considers the role of socio-economic status, geographical location and identity as risk and protective factors
2. Ensure consumer control and self-determination is central to the inquiry, including by adopting a recovery approach

Invest in mental health prevention

3. Invest in long-term evidence-based mental health prevention
4. Re-establish the Australian National Preventive Health Agency to oversee the design, implementation and monitoring of mental health prevention strategies

Build an integrated, well-funded mental health system

5. Provide long-term, sustained funding growth for mental health, with a goal to align funding levels to the burden of disease
6. Investigate funding models that better respond to individual need
7. Fund the gap in community mental health services for people not eligible for the National Disability Insurance Scheme (NDIS)
8. Identify funding models for community service organisations that are sustainable, flexible and reduce burdensome reporting requirements
9. Undertake comprehensive rural mental health workforce planning, incorporating the government, not-for-profit and private sector workforces
10. Identify strategies to recruit and retain skilled mental health workers in the system
11. Improve support for and identify opportunities to expand the role of peer workers
12. Investigate ways to support and develop consumer led and operated services
13. Critically review the responsibilities and accountabilities of different levels of government and promote more coordinated planning
14. Review the evidence for state and territory based Mental Health Commissions, and consider establishing one in each jurisdiction
15. Develop a nationally consistent approach to defining and measuring population level outcomes
16. Consider how programs reach people experiencing disadvantage and address health inequity

Address comorbidities and conditions related to mental illness

17. Design and implement strategies to improve the physical health of people with mental illness
18. Ensure consumers are provided with information by general practitioners and mental health professionals, about medications and their side-effects
19. Strengthen pathways between mental health and other healthcare providers
20. Encourage universal screening in mental health and alcohol and other drugs services
21. Investigate models for more integrated treatment and support options for people experiencing co-occurring mental health and substance use disorders
22. Develop a framework for understanding trauma, abuse and mental health and delivering trauma-informed responses

Provide an adequate income

23. Increase Newstart, Youth Allowance and related payments by $75 per week to better support people with mental health conditions, as well as carers
24. Remove unfair restrictions on access to the Disability Support Pension

Support carer and families

25. Continue the federally funded Carers and Work program
26. Improve access to respite and peer support programs for carers and family members

Recognise the connection between mental health and housing

27. Develop a National Housing Strategy identifying federal, state and local government roles and responsibilities
28. Increase the number of social housing properties across the country
29. Improve and lengthen post-release support options for people leaving prisons and hospitals
30. Investigate rolling out housing and support models (like the Housing and Support Initiative model) nationwide
31. Review catchment models of care that disadvantage people without secure housing

Address the overrepresentation of people with mental health issues in the criminal justice system

32. Fund alternatives to prison for people with a mental illness, including forensic and diversionary services
33. Undertake mental health assessments when people enter the justice system
34. Invest in court and legal assistance services that are targeted at people with mental illness
35. Better resource justice health systems to meet the mental health needs of people in prison

Support the mental health needs of children and young people at school

36. Provide schools with more resources to employ wellbeing staff, including counsellors, youth workers and nurses
37. Recognise the need for all staff in schools to have some mental health training and expertise
38. Promote the benefits of ‘schools as community hubs’ models

 

 

Adopt a social determinants approach

Recommendations

• Adopt a social determinants approach that examines mental health over the lifecourse, and considers the role of socio-economic status, geographical location and identity as risk and protective factors
• Ensure consumer control and self-determination is central to the inquiry, including by adopting a recovery approach

Use a social determinants of mental health approach

Mental health is shaped by a person’s social, economic, and physical environment. The Commission should adopt a social determinants of mental health model for this inquiry, such as that used by the World Health Organization (WHO).[4] A social determinants of mental health (SDMH) model reframes mental health, and allows for an examination of the challenges that people experience as a result of their mental illness and broader factors beyond the individual’s systemic disadvantage.

The Commission should be careful to avoid adopting an individualised medical approach to mental health that focuses on diagnosis and medical treatment of disease. This approach fails to recognise that many of the challenges people with mental illness face are not directly related to their diagnosis, but are a result of the environment they live in, and the community attitudes and expectations towards them. Some consumers also report they can feel labelled and stigmatised by an over-emphasis on diagnosis.

A SDMH approach allows for recommendations to be made around prevention of mental illness at a population and individual level. Considerations can also be given to more comprehensive prevention and early intervention initiatives.

Examine mental health over the life course

The WHO highlights the poor health outcomes of population sub-groups. It also states that ‘disadvantage starts before birth and accumulates through life’.[5] The WHO cites a significant body of work that emphasises the need for a life course approach to addressing mental health.[6]

It is important that the Commission looks at risk and protective factors for mental illness across the life course. People may have different experiences of mental wellbeing as they moves through the stages of infancy, early childhood, adolescence, working years and older years.

One in seven children experience mental health issues, and about half of all serious mental health issues in adulthood begin before the age of 14.^[7] Childhood experiences of trauma, family violence, or contact with the child protection system can significantly affect mental health. At present, VCOSS members note significant gaps in service delivery as a person moves from early childhood to adolescence.

There are varying influences across the life course that affects a person’s mental health. This includes homelessness and insecure housing, gambling, alcohol and other drugs, poor physical health, complex needs, social isolation, disaster, bullying, violence and stigma.

Australia’s medical, crisis driven approach to mental illness, has not been effective. A whole of government approach that views mental illness from a life course perspective could be game changing.

Examine how socio-economic status and other factors affect mental health

One in seven Victorians live in poverty.[8] Social and inter-generational disadvantage significantly impacts on mental health.[9] The Commission can take socio-economic status and other factors into account in examining diverse experiences of mental wellbeing, including:

• Poverty, and the mental impact of financial stress and barriers to accessing services
• Unemployment, and how it affects a person’s mental wellbeing
• Homelessness, including the large numbers of people with mental illness seeking homelessness support.^[10]
• Justice system contact, for example, how incarceration affects mental health
• Health status, such as the relationship between mental health and physical health
• Education and literacy, for example, how education affects mental health literacy
• Social isolation and loneliness, for example the impact on older people

• Colonization and the enduring effect on Aboriginal and Torres Strait Islander people, including the impact of historical injustices, such as the Stolen Generation

Examine the effect of geographical location on mental illness

Geographical location can affect people’s experience of mental wellbeing and service access in:

• Rural areas, noting the protective factors of interpersonal connection and the impact of distance from support and services into consideration
• Regional cities and towns, including the differences in specialist access and unique capabilities and challenges of different places and communities
• Outer suburban areas, including the mental wellbeing of people in growth corridors often coupled with a lack of appropriate services.

Take an intersectional approach to identity

Intersectionality refers to the ‘interconnected nature of social categorisations – such as gender, sexual orientation, ethnicity, language, religion, class, socioeconomic status, gender identity, ability or age – which create overlapping and interdependent systems of discrimination or disadvantage for either an individual or group’.[11]

The Commission can take an intersectional approach to identity, examining wellbeing in light of these factors. This includes consideration of:

• Gender, for example, whether they are women or men, cis- or transgendered, or are intersex or have another gender identity
• Sexuality, including whether they identify as lesbian, gay, bisexual, queer, or have another sexual identity
• Cultural background, including language background, cultural attitudes to mental ill-health, and the distinct experiences of asylum seekers, refugees, newly arrived migrants and established cultural communities
• Disability, such as physical, sensory, cognitive and intellectual disabilities, including people who have a co-existing mental health condition

Adopt a recovery framework

A recovery framework focuses on the needs of people who use services rather than on organisational priorities and place the lived experience and insights of people with mental health issues and their families at the centre of the system. Recovery approaches challenge traditional notions of professional power and expertise by helping to break down power imbalances between consumers and professionals.

Recovery-oriented practice encapsulates mental health care that:

• recognises and embraces the possibilities for recovery and wellbeing created by the inherent strength and capacity of all people experiencing mental health issues
• maximises self-determination and self-management of mental health and wellbeing
• assists families to understand the challenges and opportunities arising from their family member’s experiences.

The Commission should adopt a framework that maximises consumer self-determination and power and supports consumers on their journey through recovery.

Invest in mental health prevention

Recommendations

• Invest in long-term evidence-based mental health prevention
• Re-establish the Australian National Preventive Health Agency to oversee the design, implementation and monitoring of mental health prevention strategies.

Prioritise prevention and promotion

Investment in prevention is lacking in Australia’s current approach to mental illness, which is weighted to treatment for people after they become unwell. In 2014, the Commonwealth Government spent $22.4 million on mental illness prevention programs, compared to $3.6 billion on clinical and psychosocial supports and services.[12]

It’s time for a serious re-think about Australia’s approach to mental health. Treatment is key to recovery from mental illness, but it must go hand in hand with prevention. Prevention stops people from becoming unwell in the first place.

Internationally, there is a move towards increasing resources into prevention initiatives. A recent New Zealand Government Inquiry into Mental Health and Addiction recommends a more concerted and coordinated approach to social wellbeing, promotion and prevention.[13] It notes that Wales, Sweden and the United Kingdom have recommended or implemented prevention policies.[14]

There is increasing evidence that prevention is effective in promoting mental wellbeing and preventing mental health challenges, particularly when targeted in childhood.[15] In its submission to this Commission, VicHealth notes several studies demonstrating the efficacy of prevention programs.[16] This includes:

• A 2014 systematic review that found psychological interventions were able to reduce the risk of depression by 21 percent on average compared to control groups
• A 2011 economic analysis of prevention-focused mental health interventions concluded “interventions designed to prevent adult and childhood depression, suicide, and childhood anxiety provide very good value for money.”[17]

In 2017, the Fifth National Mental Health and Suicide Prevention Plan did not include a focus on prevention of mental health conditions. Treatment and prevention must go hand in hand.  Australia needs a long-term plan for prevention of mental illness and promotion of good mental health.

The National Mental Health Commission should be in the position to design a mental health prevention plan. Ideally, the Commission could consider recommending the re-establishment of an overseeing body such as the Australian National Preventive Health Agency, which ran national prevention programs from 2009 to 2014.[18] Such an agency could be responsible for supporting a strategic cross-government approach to developing mental health prevention programs. It could oversee design, implementation and monitoring of prevention and promotion programs.

 

Tackle stigma

One of the greatest barriers to people with mental illness participating in work and community life is stigma. Negative attitudes directed at people with mental illness lead to discrimination and poor treatment.

Negative attitudes to mental illness are firmly entrenched, through language like ‘crazy’ and ‘loony’ and negative depictions on television. Damaging perceptions that people with mental illness are unpredictable, dangerous or violent also persist.

Stigma can also lead to poor treatment in hospitals and health services or ‘diagnostic overshadowing’ where medical staff assume all symptoms are related to mental illness and not comorbidities. This can lead to delayed diagnosis and challenges in getting help for physical illness and chronic conditions.

The entire community has a role in creating a mentally healthy society that supports recovery and does not discriminate against people with mental illness.

The Commission should examine evidence about education and behavioural change campaigns that work. There is some evidence that broad campaigns targeted at the general population are less effective than more targeted campaigns for mental health professionals, young people or types of workplaces.^[19]

 

 

Build an integrated, well-funded mental health system

Adequately fund the mental health system

Recommendations

• Provide long-term, sustained funding growth for mental health, with a goal to align funding levels to the burden of disease
• Investigate funding models that better respond to individual need

It is no secret that the mental health system faces significant funding shortfalls. The March 2019 report by the Victorian Auditor General found that:

The lack of sufficient and appropriate system-level planning, investment, and  monitoring over many years means the mental health system in Victoria lags  significantly behind other jurisdictions in the available funding and infrastructure, and the percentage of the population supported.”[20]

The Victorian public mental health system funding is based on an input-model that allocates funding based on the number of beds. It fails to take into account unmet demand, complexity of a person’s needs, population and cohort data and demographic changes.

There is a similar funding gap at a federal level. In 2014-15 mental health received around 5f percent of the overall health budget, despite representing 12 percent of the burden of disease.[21] Funding allocations in recent budgets have done little to close the overall gap.[22]

Funding is often redirected from community and early intervention to emergency and crisis care. This limits the ability of the system to intervene early to promote recovery and prevent people becoming unwell.

Given the magnitude of under-investment over the last several decades, we need a plan for sustained long-term funding growth that places people (not bed numbers) at the centre.

Consideration must be given to funding models that provide consumers with the mix of services that meets their individual needs. This might include package funding that draws together Commonwealth, state and other funding sources.

Invest in community mental health services

Recommendations

• Fund the gap in community mental health services for people not eligible for the NDIS
• Identify funding models for community service organisations that are sustainable, flexible and reduce burdensome reporting requirements.

The funding gap is most severe in community mental health services that provide psychosocial support, recovery and rehabilitation services. Without these critical community services, people’s mental health can spiral, making them more likely to end up in the crisis or justice system.

In Victoria, publicly-funded community mental health services have long provided psycho-social rehabilitation and support to people with mental illness. These services help people stay healthy, commit to a job or education, care for their children and families, and fully participate in community life.

Community-based rehabilitation forms one pillar of a balanced mental health system, alongside clinical treatment and disability support. After full roll-out, the NDIS will provide disability support to some people with mental illness through tailored support packages, while the Victorian Government will continue to provide clinical treatment through hospitals and community teams.

However, as this changeover occurs, Victoria faces a looming gap in mental health rehabilitation funding. Neither the NDIS nor the Victorian Government has committed to funding these services into the future, as rehabilitation is outside the scope of the NDIS.

Victoria redirected all its community-based mental health services funding to the NDIS. It is the only state to have done so.[23] In contrast, New South Wales has recently increased its investment in community-based mental health.

People who qualify for the NDIS will still be able to get help from community mental health services, but only a small number of the estimated 150,000 people experiencing severe mental illness qualify. Many others will not meet the requirements of ‘permanent disability’ or, in the case of young people, may still be awaiting a settled diagnosis. Each year, 135,000 Victorian adults rely on mental health services outside the NDIS.[24]

Mental Health Victoria estimates $200 million each year in operational funding is needed to provide adequate community mental health support to 35,900 Victorians.^[25]

Even for those who do qualify, a change in the funding model means community mental health services can’t provide as holistic and responsive a service.[26] One frustrated mental health worker says:

“Before the NDIS was in place, if a person didn’t answer a knock on the door, we used to be able to check on them two to three times a week, to see if they were OK, or needed help. But now, we can only check on them in a week’s time. That person might have been sitting in the dark for a week. By this stage they need a trip to the hospital, not the doctor.”

 

Funding is needed to enable community mental health services to continue supporting people with mental illness.

Community mental health services also face a range of challenges related to the way funding is currently designed and delivered. In the development of the Victorian 10-year Community Services Industry Plan some of the issues identified included:

• Short-term contracts and insecure funding leading to lost productivity, unstable employment, staff turnover and disrupted relationships with service users.
• The move towards person-centred, individualised funding packages across the community services industry (including through the NDIS) is welcome, but too often is accompanied by overly restrictive, inflexible funding guidelines that reduce innovation, fail to recognise the differences between cohorts and geographic locations and can lead to perverse outcomes, including organisations ‘cherry-picking’ people with less complex needs.
• Multiple funding streams, short-term contracts and poor coordination across levels of government can lead to overly burdensome reporting and regulation, costing organisations valuable time that could be used for frontline service delivery.[27]

The Victorian Community Services Industry Plan has recently been endorsed by the Victorian Government. It could inform the Commission’s work, by helping to identify new models and ways of working with community service organisations.

 

Support the development of a highly skilled mental health workforce

Recommendations

• Undertake comprehensive rural mental health workforce planning, incorporating the government, not-for-profit and private sector workforces
• Identify strategies to recruit and retain skilled mental health workers in the system

With a growing demand for mental health services across the system, many organisations are reporting they face acute workforce shortages. Community service organisations face recruitment challenges including short-term contracts, insecure work, poor pay and conditions and a lack of knowledge about mental health services.[28] Stigma around mental health and the social services industry more broadly also contributes. Community organisations also report a high degree of burnout among staff; working with vulnerable people is demanding and can be stressful and emotionally draining. Strategies are needed to make sure the community services industry is an industry of choice, providing rewarding career pathways, secure employment and good pay conditions and support to staff. This is particularly important in the mental health sector.

The NDIS pricing model is contributing to the challenge of securing a highly skilled workforce. Recent survey data from the sector indicates half of disability service providers are considering reducing service quality because of NDIS pricing.[29]

Around 1,000 qualified and experienced mental health positions are set to be lost by June 2019 due to the defunding of Victoria’s community mental health support services to fund the NDIS.[30]

Community-managed mental health organisations report that the community-based rehabilitation services they provide do not fit well into the pricing structures of the NDIS. Before the implementation of the NDIS, 90 per cent of the community-managed mental health sector held a diploma or higher qualification.[31] The NDIS pricing system does not support the continued employment of appropriately qualified mental health workers at the rates at which they were previously paid, or the attraction of new workers. Recent price increases announced by the NDIA in March 2019 may go some way towards assisting organisations to retain skilled staff.[32]

In particular, rural and regional services across the mental health system (and related sectors) report they are experiencing a critical shortage of highly skilled workers. Isolation, limited access to professional development, inadequate management and professional support and family challenges, including access to high quality education for children, spousal employment and housing all contribute to difficulties recruiting and retaining workers.  VCOSS members report some rural and regional health services are forced to use large numbers of agency staff. This leads to issues with local engagement, building trusting relationships with consumers, and continuity of care.

There are four psychiatrists for each 100,000 people in outer regional areas, compared with 13 in major cities.[33]

This shortage can also lead to higher fees being charged by available specialists, further locking out low-income people’s access to care.

As a result, VCOSS members report primary care workers, like General Practitioners (GPs), are increasingly a main support for people with mental illness in their communities. While some have training and expertise in supporting people with mental illness, this is inconsistent. A professional -development program to expand the mental health expertise of rural GPs, nurses and other primary health professionals is needed.

Strategies to address workforce shortages have often been uncoordinated and piecemeal. VCOSS supports the call from mental health peak bodies for comprehensive rural and remote workforce planning, that includes clinical and community based mental health workers, peer workers and non-mental health specialists, including GPs.[34]

 

Grow the peer workforce

Recommendations

• Improve support for and identify opportunities to expand the role of peer workers
• Investigate ways to support and develop consumer led and operated services

The expertise of people with lived experience of mental illness is extremely valuable. There are many benefits of employing people with lived experience in peer worker roles in mental health services.

Consumers perceive peer workers demonstrate greater empathy and respect, and give them hope about their recovery. Peer support has also been shown to decrease hospital admissions.[35] Peer workers have also reported greater levels of self-esteem, confidence and resilience.

Australia has a small but growing peer workforce that requires additional resourcing and support. Pathways should also be developed for peer workers outside the mental health system, in other organisations and systems that work with people with mental illness.

There is also growing evidence that services controlled and run by people with lived experience of mental illness are effective in supporting recovery.[36]

Such services tend to be characterised by consumer control, choice, voluntary participation and opportunities for decision-making by consumers.

 

Build an integrated, connected and well-targeted system

Recommendations

• Critically review the responsibilities and accountabilities of different levels of government and promote more coordinated planning
• Review the evidence for state and territory based Mental Health Commissions, and consider establishing one in each jurisdiction
• Develop a nationally consistent approach to defining and measuring population level outcomes
• Consider how programs reach people experiencing disadvantage and address health inequity

In Victoria, a person experiencing mental illness may receive healthcare from a number of services. This care may not be coordinated, primarily because they are moving through multiple systems. Care is funded and delivered by numerous agencies at federal and state government level, as well as Primary Health Networks (PHNs) and privately operated services like general practitioners, psychiatrists and psychologists. Some funding and services are also now delivered through the NDIS, further exacerbating the structural fragmentation.

The Commission can investigate how funding models may be improved to ensure that a person receives coordinated, integrated care from a number of services, regardless of the funding source. Future attempts at removing structural weakness in healthcare could reflect the need for streamlined funding and services.

Responsibility for the mental health system is fragmented. PHNs are now responsible for distributing considerable funding to mental health services, as well as regional planning and coordination. While VCOSS supports the idea of regional planning and engagement, the PHNs continue to experience challenges. The recently released Report on the PHN Advisory Panel on Mental Health highlighted challenges related to short-term contracts, thin markets in some regions, variations in PHN capabilities and engagement with hospitals and services, and inconsistencies in outcome measurement and data collection.[37]

In Victoria, Primary Care Partnerships (PCPs) are well placed to work with PHNs to undertake local planning and service integration work. They have existing strong connections with health and other services that address the range of issues that impact on mental health. However, additional funding is required to enable PCPs to expand their scope and capacity.

The Commission should consider the structural responsibilities across levels of government, and strategies for more coordinated planning and management of the mental health system. This includes reviewing the evidence around the role of mental health commissions. Mental health commissions have been established at a national level and in several states and territories in recent years. Victoria may benefit from establishing an independent agency, like a mental health commission, responsible for monitoring the system and driving system reform.

Improvements in data collection will assist in system monitoring and planning. VCOSS members report that although much data is already collected by services, it mostly measures outputs, not outcomes and is not comparable across time or funding streams. National agreement on data collection and population level outcomes will boost accountability and help services and systems measure who they are reaching and what difference they are making.

The Commission should also consider how different programs and levers impact on the most vulnerable members of the community. For example, the Better Access to Mental Health Care program has consistently been shown to have higher activity rates in more advantaged areas, and lower activity rates in lower socioeconomic areas. Other program evaluations similarly show that people living in lower socioeconomic areas or more rural areas typically receive services that provide ‘lower volume’ care and/or are provided by less highly trained professionals.[38] This result in inequities in access and outcomes of care, including for those who are most vulnerable.

 

 

Address comorbidities and issues related to mental illness

Recommendations

• Design and implement strategies to improve the physical health of people with mental illness
• Ensure consumers are provided with information by general practitioners and mental health professionals, about medications and their side-effects
• Strengthen pathways between mental health and other healthcare providers
• Encourage universal screening in mental health and alcohol and other drugs services
• Investigate models for more integrated treatment and support options for people experiencing co-occurring mental health and substance use disorders
• Develop a framework for understanding trauma, abuse and mental health and delivering trauma-informed responses

Design strategies to improve the physical health of people with mental illness

There is a clear link between serious mental illness and poor physical health, including cardiovascular disease and diabetes. The Australian study ‘People living with psychotic illness’ survey found that for one quarter of participants, their physical health was one of the biggest challenges.[39] Another Australian study showed that people living with a mental illness had an overall death rate that was two and a half times greater than the general population.[40]

Significantly improving the physical health of people with mental illness should be a key focus of the health system, and of the Commission’s inquiry. The Mental Health Commission of New South Wales recommends that the following elements are needed to produce improvements in the physical health of mental health consumers:

• changes in clinical practice
• delivery of evidence-based physical activity programs across the inpatient, community, private and community-managed sectors
• implementation of a recovery approach, including peer support services
• development of partnerships, in particular with consumers and their families/carers
• workforce development across sectors to build capacity.[41]

Mental health consumers report that they are often not informed about the side-effects of medications to treat mental illness (particularly anti-psychotics), which can include significant weight gain, high blood pressure and high blood glucose levels.[42] Consumers need to be provided with information to help them make informed choices about their medication use, and to help manage side effects. Strengthened pathways between healthcare providers and training and education is needed for medical practitioners.

Address comorbid alcohol and drug use

Rates of co-occurring substance use and mental illness are high, particularly among the most marginalised members of the community, including people experiencing homelessness and people in the justice system. For some people, addictions develop as a result of attempts to self-medicate the symptoms of mental illness or trauma. Use of alcohol and other drugs can also lead to or exacerbate some mental illnesses.

However, people can recover from co-occurring mental health and substance use disorders, if they are able to access integrated treatment options.

VCOSS members report that program funding restrictions and strict eligibility guidelines mean that often people are turned away from both mental health and AOD services. Instead of the ‘no wrong door’ approach that is recommended to increase engagement with services, too often people find themselves facing a ‘no right door’ scenario.

The Commission should examine strategies that encourage services to undertake universal screening at all entry points for mental health and substance use problems, to identify co-occurring issues. Increased funding for care coordination and workforce development around comorbidity practices are also important.

Develop a framework for addressing trauma

The message from people with lived experience is clear: address the role that trauma plays in contributing to mental illness. A traumatic event is something that threatens a person’s life or safety, or the lives of people around them. It’s an experience that’s stressful and has a significant impact on a person’s emotional state.[43]

The Commission should consider the impact of trauma when making recommendations for mental health reform. The cost of childhood trauma is high; the unresolved cost of childhood trauma is estimated to be at $6548 per adult survivor.[44] There are many implications for childhood trauma, including reduced life expectancy, chronic disease, tobacco smoking, alcohol consumption, obesity, suicide, mental illness and exposure to the criminal justice system.

Intergenerational and collective trauma for Aboriginal and Torres Strait Islander children,[45] young people and adults should also be considered. Trauma may be experienced directly through abuse, neglect and exposure to violence, or via secondary exposure. This can include witnessing past traumatic events of family and community such as colonisation, forced removals and the effects of government policies.

The Commission should give consideration to how the lack of trauma-informed care affects individual mental health. Failure to provide trauma-informed services and expertise as well as poor or inequitable access to trauma-specific services exacerbates mental and physical health issues for consumers and escalates the risk of suicide and deliberate self-harming behaviours.^[46]

VCOSS would like to see recommendations for the development of a framework for understanding trauma, the impacts of abuse, and the root causes of mental illness. This framework should also include recommendations for a trauma-informed approach to care for people who have experienced trauma.  Methods such as seclusion and restraint cause more trauma for people experiencing mental illness. The Commission must look at harms and abuse in the current system. As stated by one member:

You can’t have a good mental health system if you don’t define what a safe service looks  like.

Build people and communities’ resilience to disasters

Evidence suggests that individuals who survive disasters experience a broad spectrum of emotional responses, which may vary from short to long term, and which are likely to change over time. In post-disaster populations, higher than average rates are found for a range of conditions including depression, anxiety disorders, complicated grief, substance abuse and somatic, or physiological symptoms.

The WHO estimates however that twelve months after an emergency there will be an increased prevalence of severe mental health problems (from 2-3 per cent to 3-4 per cent), and an increase in moderate mental disorders (from 10 per cent to 20 per cent).[47] Although post-disaster distress is likely to decline over time, the effects of the initial disaster and losses are likely to persist. A significant group at risk for these problems are the bereaved, including those who live outside the affected areas.

Psychological impact and distress following a major disaster is likely to be greater in those who:

• Experience a high sense of threat to life (either their own lives or that of significant others)
• Have been exposed to widespread death and destruction
• Have been physically injured by the event
• Have experienced multiple losses (e.g.significant others, property, community, etc.)
• Have experienced a high level of community destruction and consequent disruption to community and social systems
• Have limited social support
• Are socially and economically disadvantaged, or
• Have low pre-existing psychological resilience[48]

Certain groups within the population have been found to be more vulnerable to the impacts of disasters. These include: children, young people and their families; the elderly; people with a disability; those with a pre-existing mental health issue; and the bereaved.[49]

Research shows that three to four years after the 2009 Victorian bushfires, the majority of people were recovering following the disaster experience and its aftermath[50]. However a significant minority were reporting symptoms which indicated mental health problems that were beyond levels likely to be manageable and may require professional support. This is approximately twice the level expected in a population not affected by disaster. Severe psychological distress was predicted by fear for one’s life in the bushfires and death of someone close in the bushfires.

Five years after the fires, rates of mental health problems had significantly reduced to 21.9 per cent in high impact communities but were still higher than national levels. While many people showed signs of improved mental health over time, there were others with delayed onset of mental health problems such as post-traumatic stress disorder.[51]

 

 

Provide an adequate income

Recommendations

• Increase Newstart, Youth Allowance and related payments by $75 per week to better support people with mental health conditions, as well as carers
• Remove unfair restrictions on access to the Disability Support Pension

Poverty and income disadvantage are directly related to poor mental health.[52] Mental ill-health can lead to reduced income and employment, which entrenches poverty and in turn increases the risk of poor mental health.

People are better able to manage and prevent mental health conditions if they can afford shelter, proper nutrition, adequate energy use, and transport to reach health services and social supports. More than 1 in 4 people in the poorest 20 per cent of Australians have current psychological distress at a high or very high level, compared to about 1 in 20 of the richest 20 per cent of Australians.[53] Financial hardship, including an inability to pay bills and repay debts, is also associated with poor mental health.

People with mental health conditions can face greater risk of financial hardship because of additional health care and pharmaceutical costs, which are under-funded through the public health care system and can result in high out-of-pocket costs.[54] The majority of people receiving the Disability Support Pension (DSP) or Newstart report being concerned about health and medical expenses.[55]

The DSP, Newstart and Carers payment are inadequate for people with mental health conditions and carers. Poverty rates are particularly high among people receiving Newstart (55 percent of recipients), as well as the DSP (36 percent of recipients) and Carers Payment (17 percent of recipients).[56] Carers are restricted in the amount and type of employment that they can secure. Many unemployed carers who provide a substantial amount of care, but do not qualify for the Carer Payment, rely on Newstart for income.[57] Carers face many challenges when it comes to securing employment. Less than half (45.6 percent) of primary carers who spend 20 to 39 hours per week caring are employed.[58]   An increase in Newstart would provide them with better support as they look for employment.

VCOSS members report that an increasing number of people with long-term mental health conditions are being diverted from the higher paying DSP, as a result of a stricter disability threshold. Unfair restrictions on access to the DSP, including where a person’s condition is not ‘fully assessed or stabilised’ should be removed or addressed.

The Commission should recommend increasing Newstart, to allow people with episodic mental health conditions and their carers to survive recurring periods out of the workforce without falling into poverty and experiencing worse mental health. A Newstart increase will better support people with long-term mental health conditions who are unable to access the DSP. The Australian Council of Social Service, along with other Councils of Social Service, recommends Newstart and related allowances be raised by $75 per week to cover the current minimum costs of essentials, such as housing, food, transport and health care, consistent with the New Minimum Budget Standards for Low-paid and Unemployed Australians.[59]

Youth Allowance should also be increased alongside Newstart. Of all income support recipients, poverty rates are highest among those receiving Youth Allowance, at 64 per cent of recipients. Youth Allowance can be increased in line with Newstart, to better reflect the cost of independent living and enable young people to avoid the poverty and financial hardship that can cause or compound mental health conditions.

 

Support carers and families

Recommendations

• Continue the federally funded Carers and Work program
• Improve access to respite and peer support programs for carers and family members

Carers and informal family support contribute much to the Australian economy. Australia’s 240,000 carers for people with mental health issues contribute an estimated $13.2 billion in informal care per annum.[60] But carers are vulnerable to developing chronic physical problems, their own mental health issues, and falling into poverty.[61]

Some carers report changes and reduction in supports available to them through the transition to the NDIS. Carers cannot get an NDIS plan or funding package in their own right, but some supports for carers can be funded if they directly relate to the person with disability. However, some carers report that respite will not be funded, although a similar service type may be funded under a different name.[62] This is especially challenging for older carers who are familiar with the term respite. Others report that the NDIS is over-reliant on carers, only funding other support when informal supports are exhausted.[63]

In the past carers were able to access planned respite, as well as other services like self-help and mutual support groups, through a number of national and state programs. These are often no longer available or are transitioning to the NDIS.[64]

There is also not enough information available to carers to help them navigate the system for themselves and their loved ones. VCOSS members reported that the constant barriers carers face is ‘demoralising’ and ‘takes a toll’ on their physical and mental health.

 

Carers should be provided with opportunities and support to attain work, study or volunteer placements and to remain in work. The Commission must examine effective strategies for supporting carers in the workplace. Several VCOSS members spoke highly of the Australian Government’s Carers and Work Program. Carers and Work provides intensive support to carers of people with mental illness to address non-vocational barriers to achieving workforce participation. However, it was the understanding of some participants that changes to the program arising from the roll-out of the NDIS may threaten its effectiveness.

 

Recognise the connection between mental health and housing

Recommendations

• Develop a National Housing Strategy identifying federal, state and local government roles and responsibilities
• Increase the number of social housing properties across the country
• Improve and lengthen post-release support options for people leaving prisons and hospitals
• Investigate rolling out housing and support models (like the Housing and Support Initiative model) nationwide
• Review catchment models of care that disadvantage people without secure housing

People who are experiencing mental ill-health are more at risk of losing their housing, and falling into homelessness. Shortage of housing stock is a huge issue, for people experiencing mental illness and other forms of disadvantage such as family violence. VCOSS members estimate that in Victoria, an additional 30,000 new social housing properties are needed over the next decade just to meet demand.[65]

Across Australia, it is estimated that an additional 23,000 dwellings are needed each year in order to reach a projected target of 658,000 social housing dwellings by 2026.[66] A coherent National Housing Strategy is needed to determine the respective roles and responsibilities of federal, state and local governments to meet this target.[67]

Homelessness is also a cause of poor mental health. Last year 17,772 Victorians presented at homelessness services citing mental health as one of the reasons they need help.[68] Many people’s first episode of mental illness develops as a consequence of the stress and dislocation of homelessness. The number of people referred to homelessness services from mental health services has grown by 41 per cent over the past five years.[69]

Being homeless also limits people’s ability to access clinical mental health services. VCOSS members noted that in Victoria, clinical ‘catchment areas’ are assigned based on a person’s home address. If someone is homeless, they may not be assigned to any area.

The Commission should investigate “Housing First” combined with wrap-around support services that meet people’s individual needs and help people to retain tenancies. VCOSS members highlighted the Housing and Support Initiative (HASI) model in NSW that promotes recovery and supports people with mental illness to live independently and participate in the community through a combination of housing, clinical and psychosocial rehabilitation support.

Far too many people are released from hospital and prison into homelessness. Due to the chronic shortage of affordable accommodation in Victoria, over 500 people each year are discharged from acute mental health care into rooming houses, motels, rough sleeping or other forms of homelessness.[70] Similarly, a third of people leaving prison expect to be homeless, making them more likely to re-offend. Following release from prison, those experiencing comorbid homelessness and mental ill-health are 40 times more likely to be arrested and 20 times more likely to be imprisoned than those in stable accommodation.[71]

To lead successful, productive lives in the community, people leaving prison need support before and long after they leave. In particular, this support can focus on finding and maintaining housing, sustaining their mental health, and treating problem drug and alcohol use. Currently, transition programs are under-resourced, only target the highest-risk prisoners, and only support people for a couple of months.

Post-release support services can be expanded to more people, and assist for up to a year after release. The ACT model of aftercare is a good example, supporting people for 12 months after they leave prison.[72] The program has reduced recidivism, with participants reporting increased self-esteem, improved confidence, a greater quality of life and an enhanced ability to achieve goals.[73]

 

 

Address the overrepresentation of people with mental health issues in the criminal justice system

Recommendations

• Fund alternatives to prison for people with a mental illness, including forensic and diversionary services
• Undertake mental health assessments when people enter the justice system
• Invest in court and legal assistance services that are targeted at people with mental illness
• Better resource justice health systems to meet the mental health needs of people in prison

People with a mental illness are over-represented in the criminal justice system. Sixty per cent of Victorian people who enter prison report being diagnosed with a mental health disorder prior to imprisonment.^[74] Aboriginal and Torres Strait Islander people in prison are also more likely to experience mental illness.[75]

Improved clinical services, greater social support, targeted drug and alcohol services and specialised community forensic services should be expanded to reduce offending by people with a mental illness.

People with mental illness exhibiting anti-social behaviours could often be better treated with a health response, not a criminal justice response. For example, people who are experiencing homelessness that have a mental illness may be more likely to fall foul of laws concerning drunkenness, offensive behaviour, disorderly conduct, loitering or vagrancy. Victoria Police performs a critical role responding to these types of incidents involving people with a mental illness, in crisis or under the influence of alcohol and drugs. Where the offence committed is not seriously damaging to others, a structured service that diverts mentally ill offenders away from the criminal justice system and into health services should be established.

When a person does enter the justice system, their mental health needs should be immediately identified. However, there are not enough points where assessments take place. Where assessments for a mental illness are conducted, the threshold for accessing services may be too high, or linked to another factor such as a person’s assessed risk of re-offending. This approach means that people who need support or intervention for a mental health issue may not receive it because they have a lower assessed risk profile than other people in the criminal justice system.

People in the criminal justice system experiencing mental illness have the right to fair treatment and to understand the court process that they are a part of. On some occasions, this may mean that normal legal and criminal justice processes should be modified to accommodate the needs of the individual. For example, the Magistrates’ Court of Victoria has successfully piloted specialist courts and programs to divert offenders with a mental illness to treatment, and address the causes of their offending. The specialist courts and programs play a key role by reducing rates of imprisonment.^[76]

More of these specialist courts and support programs, that maximise outcomes for offenders with a mental illness, are needed. Funding for appropriate diversionary programs and services, non-custodial accommodation needs to be delivered to empower the courts to make decisions that divert people with a mental health issue from custody into other rehabilitative settings. To support these changes, the legal assistance sector should be provided with funding to deliver services that allow for more a specific focus on the mental health needs of clients.

Within prisons, the high rate of mental illness among prisoners means that as prisoner numbers increase, so does demand for under-resourced mental health and disability services within the correctional system. People are leaving prison without getting the treatment and rehabilitation they need, because the services are not available. Additional investment in thorough care and transition supports are required.[77]

 

 

Support the mental health needs of children and young people at school

Recommendations

• Provide schools with more resources to employ wellbeing staff, including counsellors, youth workers and nurses
• Recognise the need for all staff in schools to have some mental health training and expertise
• Promote the benefits of ‘schools as community hubs’ models.

Young people are particularly vulnerable to poor mental health. Mission Australia’s Youth Mental Health Report found more than 1 in 4 young people who responded to the survey met criteria for a probable mental illness.[78] Half of all lifetimes mental illnesses emerge by age 14, and three quarters by age 24.[79]

The Youth Mental Health Report also found less than 1 in 4 young people with a diagnosed mental illness access a health service for support in the previous 12 months. Sixty percent reported they were not comfortable seeking information, advice or support from professional services, including community organisations and counsellors.[80]

VCOSS members report seeing an increasing number of children with mental health issues, including anxiety, behavioral issues and exhibiting self-harm.[81] However, there is a significant gap in services for very young children. For example, the number of headspace sites across the state is growing, with additional funding allocated in the recent federal budget[82]. Headspace provides support for children over the age of 12. However, they are unable to help children aged 11 years and under.[83]

Schools play a vital role in promoting and encouraging good mental health, and in identifying children and young people at risk of illness, and acting early to prevent them becoming more unwell. Schools have the opportunity to build trusting relationships with children and young people, making them more likely to disclose if they are experiencing difficulties.

VCOSS members highlighted the need for whole school commitments to mental wellbeing, from the school council down to individual students. The Doveton model in Victoria was highlighted, for its role as a ‘school community hub model.’ They have health services on site to improve accessibility for children and families, including visiting psychologist. This model is being built on across the state through the Our Place initiative.[84]

However, consultation participants noted that many schools lack funding for wellbeing programs, and need more youth workers, nurses and counsellors. They welcomed the recent investment by the Victorian Government in the Mental Health in Schools program, employing over 190 qualified mental health professionals, including counselors, youth workers and psychologists. However some members have noted that this initiative needs to be extended to primary school students. Principals have raised concerns about children as young as five self-harming, exhibiting behavioural issues and experiencing anxiety.[85] Others noted the importance of all staff in schools having the skills to identify and support children with mental illness, and deliver trauma informed care.

“We had 400 kids in one school with one counsellor.

But what if multiple teachers, the footy coach and the groundkeeper all had the skills needed?”

[86]

 

[1] Royal Australian and New Zealand College of Psychiatrists, 2016, The economic cost of serious mental illness and comorbidities in Australia and New Zealand.

[2] Mental Health Victoria, Saving Lives. Saving Money. 2018.

[3] Daniel Andrews Royal Commission into Mental Health  https://www.danandrews.com.au/royal-commission-into-mental-health, media release, 24 October 2018.

[4] World Health Organisation Social Determinants of Mental Health Geneva 2014

[5] Ibid

[6] Ibid

[7] Lawrence D, Johnson S, Hafekost J, Boterhoven De Haan K, Sawyer M, Ainley J, Zubrick SR ,2015 The Mental Health of Children and Adolescents. Report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing, 2015.

[8] Victorian Council of Social Service, Every Suburb Every Town – Poverty in Victoria, 2018

[9] World Health Organisation, Social Determinants of Mental Health Geneva, 2014

[10] Australian Institute of Health and Welfare. Mental health services—in brief, 2018.

[11] Victorian State Government, Family Safety Victoria, Everybody Matters – Inclusion and Equity Statement, 2019.

[12] National Mental Health Commission, The National Review of Mental Health Programmes and Services, 2015

[13] New Zealand Government, Government Inquiry into Mental Health and Addiction He Ara Oranga, 2018

[14] Ibid

[15]  Arango, C, Diaz-Caneja, P, McGorry, P, et al Preventive strategies for mental health. Lancet Pscyhiatry 5: 591-604, 2018

[16]Vichealth and partners Focusing on prevention A joint submission to the Commission inquiry into mental health 2019;

Arango, C, Diaz-Caneja, P, McGorry, P, et al Preventive strategies for mental health. Lancet Pscyhiatry 5: 591-604, 2018;

McDaid, D., & Park, A. Investing in mental health and well-being: findings from the DataPrev project. Health Promotion International, 26(suppl_1), i108-39, 2011; Knapp, M., McDaid, D., & Parsonage, M. Department of Health/Personal Social Services Research Unit, Centre for Mental Health, Institute of Psychiatry: Mental health promotion and mental illness prevention: The economic case. Journal of Poverty & Social Justice, 19(3), 297-299, 2011; Mihalopoulos, C., Vos, T., Pirkis, J., & Carter, R. The economic analysis of prevention in mental health programs. Annual Review of Clinical Psychology, 7, 169-201, 2011

[17] Mihalopoulos, C., Vos, T., Pirkis, J., & Carter, R. The economic analysis of prevention in mental health programs. Annual Review of Clinical Psychology, 7, 169-201, 2011

[18]Australian Government https://www.directory.gov.au/portfolios/health/australian-national-preventive-health-agency, 2019

[19] Director General for Health and Consumers, Countering the stigmatization and discrimination of people with mental health problems in Europe, accessed online March 2019 http://ec.europa.eu/health/archive/ph_determinants/life_style/mental/docs/stigma_paper_en.pdf

[20] Victorian Auditor-General’s Office, Access to mental health services, March 2019.

[21] AIHW, Health expenditure Australia 2014-15, 2016.

[22] Sebastian Rosenberg, Mental health funding in the 2017 budget is too little, unfair and lacks a coherent strategy, The Conversation, May 11 2017.

[23] Mental Health Victoria Saving Lives Saving Money 2018

[24] Ibid

[25] ibid

[26]National Disability Services, State of the Disability Sector Report 2018, 2018.

[27] VCOSS, 10 year Community Services Industry Plan, 2018.

[28] VCOSS, Community Services Industry Plan; Consultation Report, February 2018.

[29] National Disability Services, State of the Disability Sector Report 2017, 2017.

[30] Ibid.

[31] Community Mental Health Australia, NDIS Costs – Commission Issues Paper, 2017.

[32] Ministers for the Department of Social Services, NDIS price increases for a sustainable and vibrant disability services market, 30 March 2019, accessed online https://ministers.dss.gov.au/media-releases/4761

[33] National Rural Health Alliance, Mental Health in rural and remote Australia, December 2017.

[34] For example, Pro Bono Australia, New strategy needed to address rural mental health crisis, January 2018.

[35] Mental  Health Foundation (UK), Peer Support, accessed online https://www.mentalhealth.org.uk/a-to-z/p/peer-support

[36] Sax Institute, Evidence check; The effectiveness of services led or run by consumers in mental health, 2015.

[37] PHN Advisory Panel on Mental Health, The report of the PHN Advisory Panel on Mental Health, 2019.

[38] Graham N Meadows, Joanne C Enticott, Brett Inder, Grant M Russell and Roger Gurr, Better access to mental health care and the failure of the Medicare principle of universality, Medical Journal of Australia 202(4), 2015, p 190.

[39] Morgan VA, Waterreus A, Jablensky A, et al. People living with psychotic illness in 2010: The second Australian national survey of psychosis. Australian and New Zealand Journal of Psychiatry. 2012;46(8), p 735.

[40] Coghlan R, Lawrence D, Holman CDJ, Jablensky AV. Duty to care: Physical illness in people with mental illness, 2001

[41] Mental Health Commission of New South Wales, Living well; putting people at the centre of mental health reform in NSW: A report, 2014.

[42] For example in Mental Health Commission of New South Wales, Medication and mental illness; Perspectives, 2015.

[43] Headspace https://headspace.org.au/young-people/understanding-trauma-for-young-people/  2019

[44] Kezelman, C., Hossack, N., Stavropoulos, P., Burley, P. The Cost of Unresolved Childhood Trauma and Abuse in Adults in Australia, Adults Surviving Child Abuse and Pegasus Economics (BlueKnot), 2015

[45] Australian Institute of Health and Welfare, Trauma-informed services and trauma-specific care for Indigenous Australian children, 23 Jul 2013, accessed at https://www.aihw.gov.au/reports/indigenous-australians/trauma-informed-services-and-trauma-specific-care-for-indigenous-australian-children/contents/table-of-contents

[46] Bateman, J & Henderson, C (MHCC) Kezelman, C (Adults Surviving Child Abuse, ASCA) Trauma-Informed Care and Practice: Towards a cultural shift in policy reform across mental health and human services in Australia, A National Strategic Direction, Position Paper and Recommendations of the National Trauma-Informed Care and Practice Advisory Working Group, 2013

 

[47] Australian Healthcare Associates, Evaluation of the psychosocial response to the 2009 Victorian bushfires, Melbourne 2010

[48] Ibid.

[49] Ibid.

[50] Gibbs L et al, Beyond Bushfires: Community Resilience and Recovery Final Report, University of Melbourne, Victoria, November 2016

[51] Gibbs L et al, Beyond Bushfires: Community Resilience and Recovery Final Report. November 2016, University of Melbourne, Victoria, Australia

[52] A N Isaacs, J Enticott, G Meadows and B Inder, ‘Lower Income Levels in Australia Are Strongly Associated With Elevated Psychological Distress: Implications for Healthcare and Other Policy Areas’ Front. Psychiatry (2018) 9:536. doi: 10.3389/fpsyt.2018.00536.

[53] A N Isaacs, J Enticott, G Meadows and B Inder, ‘Lower Income Levels in Australia Are Strongly Associated With Elevated Psychological Distress: Implications for Healthcare and Other Policy Areas’ Front. Psychiatry (2018) 9:536. doi: 10.3389/fpsyt.2018.00536.

[54] For example, see recent report released by Australian Institute of Health and Welfare shows that Australians are paying more for healthcare than most other developed nations, forking out $34 billion a year on out-of-pocket health costs – see https://www.theage.com.au/federal-election-2019/missing-out-on-basic-healthcare-australians-spend-34-billion-a-year-on-out-of-pocket-health-costs-20190415-p51ebe.html

[55] Councils of Social Service, Payment adequacy: A view from those relying on social security payments, 2015, 23.

[56] P Davidson, P Saunders, B Bradbury and M Wong, Poverty in Australia, 2018, ACOSS/UNSW Poverty and Inequality Partnership Report No. 2, Sydney, Australian Council of Social Service, 2018, 15.

[57] Carers Australia, Budget 2019: What it means for carers, 2019, accessed at https://www.carersaustralia.com.au/storage/budget-2019-what-it-means-for-carers-final.pdf

[58] Australian Bureau of Statistics 2015 Survey of Disability, Ageing and Carers

[59] Australian Council of Social Service, ‘Raise the rate: Increase Newstart and related payments’, March 2018, https://www.acoss.org.au/wp-content/uploads/2018/03/Raise-the-Rate-Explainer-1.pdf; P Saunders and M Bedford, New Minimum Income for Healthy Living Budget Standards for Low-Paid and Unemployed Australians, UNSW Sydney, August 2017.

[60] Mind Australia, The economic value of informal mental health caring in Australia; summary report, 2017.

[61] Ibid.

[62] Carers Australia, Position paper: NDIS Reasonable and necessary supports-  the case for respite, October 2018.

[63] Ibid.

[64] Carers Australia, Accessing respite through the NDIS, 21 December 2017.

[65] Community Housing Federation of Victoria, Quantifying the shortfall of social and affordable housing, 2016.

[66] Everybody’s Home, Social and Affordable Housing Projections for Australia 2016-2026/2036, 2018 https://everybodyshome.com.au/wp-content/uploads/2018/04/EH_researchreport_190418-1.pdf

[67] Ibid.

[68] AIHW, Specialist homelessness services annual report 2017-18, 2019, accessed online at https://www.aihw.gov.au/reports/homelessness-services/specialist-homelessness-services-2017-18/contents/contents

[69] Ibid.

[70] Ibid.

[71] (NSW Department of Corrective Services, 2004, Submission to Experiences of Injustice and Despair in Mental Health Care in Australia consultations by the Mental Health Council of Australia and the Brain and Mind Research Institute in association with the Human Rights and Equal Opportunity Commission, cited in Mental Health Council of Australia, 2014, Not for Service, p.220)

[72] A Griffiths et al, Evaluation of ACT Extended Throughcare Program: Final Report, Social Policy Research Centre, UNSW, 2017.

[73] Ibid.

 

[74] Australian Institute of Health and Welfare, The health of Australia’s prisoners 2015, 2015.

[75] Ibid.

[76] Victorian Auditor General, Mental Health Strategies for the Justice System, 2014. P. xi

[77] Australian Law Reform Commission Prison Programs, Parole and Unsupervised Release https://www.alrc.gov.au/publications/provision-throughcare

[78] Mission Australia, Youth Mental Health Report, 2016.

[79] Ibid.

[80] Mission Australia, Youth Mental Health Report, 2014.

[81] Also see for example, The Age, Principals sound the alarm on mental illness in primary school kids, April 2 2019.

[82] Federal Budget 2019: Mental health highlighte, Headspace expanded to adults as Coalition tackles Australia’s rising suicide rate  https://www.smh.com.au/business/the-economy/federal-budget-2019-adult-headspace-to-be-trialled-as-government-boosts-mental-health-and-primary-care-20190328-h1cwum.html April 2, 2019

[83] Headspace Who we are https://headspace.org.au/about-us/who-we-are/, 2019

[84] Our Place accessed online https://ourplace.org.au/our-work/

[85] The Age, Principals sound the alarm on mental illness in primary school kids, 2 April 2019

https://www.theage.com.au/national/victoria/principals-sound-the-alarm-on-mental-illness-in-primary-school-kids-20190402-p51a25.html

[86] VCOSS consultation participant.