National Aboriginal and Torres Strait Islander Leaders in Mental Health
Submission on the National Mental Health Commission’s Review of Mental Health Services and Programmes, 17 April 2014
The review’s Terms of Reference require it to address the ‘specific challenges for Aboriginal and Torres Strait Islander people[s]’ as they relate to the review’s wider mandate. We start our submission by setting out those challenges and then focus on how the review could address these in a systematic fashion.
1. What are the specific challenges facing Aboriginal and Torres Strait Islander peoples?
The rates of mental health conditions and suicide among Aboriginal and Torres Strait Islander peoples are almost double that of other Australians and are of national concern (see Appendix). We refer to this as the ‘mental health gap’. The reasons for this are:
· The impact of colonisation and ensuing adverse social determinants. Aboriginal and Torres Strait Islander mental health is underpinned by a broader, and uniquely Aboriginal and Torres Strait Islander construct of health known as social and emotional wellbeing.[1] This includes healthy connections to body, mind and emotions, family, community, the spiritual dimension of existence and traditional lands. For many communities, such negative factors are impacting on the healthy connections that comprise their social and emotional wellbeing and hence the mental health of their members. Some of these determinants are shared with other Australians – poverty, unemployment, poor housing, alcohol and substance use among them. Others, however, are unique – including racism, the impacts of the Stolen Generations’ policies and cultural stress. The importance of social and emotional wellbeing to Aboriginal and Torres Strait Islander mental health, and health in general, is recognised in the soon to be renewed National Aboriginal and Torres Strait Islander Social and Emotional Wellbeing Framework and the 2013 National Aboriginal and Torres Strait Islander Health Plan.
· Aboriginal and Torres Strait Islander peoples, historically and today, enjoy significantly less access to mental health and related services and programs than other Australians. By ‘accessible services’, we mean by location and cost; services that do not discriminate; and services that are culturally acceptable to Aboriginal and Torres Strait Islander peoples (or
‘culturally competent’). In fact, underlying the mental health gap is also an ‘access gap’ to mental health and related services. In the 2008 ABS National Aboriginal and Torres Strait Islander Social Survey, 34.5 per cent of respondents reported high or very high rates of psychological distress also reported access problems to health services.[2] According to the Australian Institute of Health and Welfare, In 2009-10, Aboriginal and Torres Strait Islander as private patients used mental health professionals at significantly lower rates than other Australians: psychologist care (81 v 135 per 1,000) and psychiatric care (45 v 87 per 1,000). [3] Further, while a higher percentage of Aboriginal and Torres Strait Islander encounters with GPs were mental health-related compared with those for non-Indigenous Australians (15.3% versus 11.8%), taking population size and age structure into consideration Aboriginal and Torres Strait Islander people had a lower rate of encounters than non-Indigenous Australians (490.7 and 567.2 per 1,000 population respectively).[4]
Improving Aboriginal and Torres Strait Islander mental health and reducing suicide requires:
· Shifting the focus from providing biomedical forms of treatment for mental health conditions that are preventable to a genuinely preventative population mental health approach. Such would involve:
· Improving social and emotional wellbeing including by community empowerment programs that build on cultural strengths. This is particularly important in relation to suicide prevention.
· Addressing the adverse determinants that contribute to Aboriginal and Torres Strait Islander mental health conditions and suicide.
· Ensuring Aboriginal and Torres Strait Islander peoples have equal access to mental health services as other Australians, taking into account their greater levels of need.
Closing the mental health gap should not be a matter of responding to crisis after crisis as they occur, but rather should involve a preventative address to the determinants that undermine Aboriginal and Torres Strait Islander mental health in addition to addressing the services gap. This also involves building on the cultural strengths within families, communities and individuals.
2. Identifying existing funding for social and emotional wellbeing, mental health and suicide prevention services for Aboriginal and Torres Strait Islander peoples
In the following table are listed services and programs and their private, government and non-government funding sources.
Broad type / Examples / FunderCommonwealth Aboriginal and Torres Strait Islander-specific programs / · ATAPS (Aboriginal and Torres Strait Islander-specific) /Medicare Locals
· Suicide Prevention funding (through the TATS package)
· Grants for specific programs / Primary and Mental Health Care Division of the Department of Health
National Aboriginal and Torres Strait Islander Healing Foundation / Department of Social Services.
Commonwealth mainstream mental health, disability and recovery support programs / · Mainstream ATAPS/ Better Access
· Access to psychiatrists program
· NDIS – support for psychiatric disability
· Partners in Recovery, PHaMs, MH Respite, Support for Day to Day Living
· Phone/ internet services
· Family mental health services
· EEPIC
· Headspace
· Kidsmatter
· Early childhood, men’s, school programs / Department of Health and the Department of Social Services
Mental health services provided by psychologist and psychiatrists / Private, some government support, health insurance
Mental health services provided by GPs / Medicare, private (gap payments)
Community mental health services / State and territory/ Commonwealth
Mental health services provided by public and private hospitals / · Emergency departments
· Admitted
· Ambulatory equivalent / State and territory/ Commonwealth, private, health insurance
Mental health workforce training and development / · NSW Aboriginal Mental Health Workforce Program / State/ Commonwealth
Services provided by, or through, Aboriginal and Torres Strait Islander Primary Health Care Services including Aboriginal Community Controlled Services / · SEWB Program
· Link-up
· Alcohol and substance abuse services / Indigenous and Rural Health Division of the Commonwealth Department of Health
Mental health services in prisons / State and territory/ Commonwealth
Research / NHMRC, other
Residential care / · Psychiatric hospitals
· Homes / State and territory, private, health insurance
As a necessary first step for the review, we recommend that an audit of spending on Aboriginal and Torres Strait Islander peoples across all of the above (and programs relevant to the review Terms of Reference) be carried out. This will provide a needed foundation for the review process.
3. Securing equitable funding is a challenge facing Aboriginal and Torres Strait Islander mental health
As noted, the Terms of Reference ask the review to consider the ‘specific challenges for Aboriginal and Torres Strait Islander people’ as a part of its work. Of relevance here is the mental health gap we have described and lower access to services. Based on this, we identify equity as a further challenge facing Aboriginal and Torres Strait Islander peoples, and a question that must be addressed by the review.
Achieving equitable outcomes and closing the mental health gap requires relative need to be accounted for: put simply, if “X” has double the mental health needs of “Y”, “X” will likely need twice the resources to enjoy an equitable mental health outcome to ‘Y”. This is far from a new funding model. Increased expenditure on those with increased need is an established feature of the health system: for example, older people, though a relatively small proportion of the population, but have a higher level of need and receive a large proportion of total health expenditure.
Allocating funding to account for the relative needs of Aboriginal and Torres Strait Islander peoples has an evolving history. Perhaps the most recent and outstanding success in the health field has been that of the National Health and Medical Research Council who have committed to allocating 5% of its total annual allocation to Aboriginal and Torres Strait Islander health research. The 5% figure was determined by multiplying the Aboriginal and Torres Strait Islander presence in the population (2.5% at the 2006 Census) by a health needs index (in this case, twice the non-Indigenous need).[5] This approach has been particularly successful in expanding much needed Aboriginal and Torres Strait Islander health research.
For many years the Commonwealth Grants Commission (CGC) has taken account of the relative proportions of Aboriginal and Torres Strait Islander peoples versus non-Indigenous people across Australia to determine Aboriginal and Torres Strait Islander-specific allocations among jurisdictions. In 2001 the CGC went further, using a resource allocation formula to ensure that spending on Aboriginal and Torres Strait Islander programs resulted in equitable outcomes for Aboriginal and Torres Strait Islander people living in urban versus remote areas, taking into account the relatively greater need of the latter.[6] Similar formulae are widely used today - including by state and territory Governments for hospitals and area health services.
What is equitable spending on Aboriginal and Torres Strait Islander mental health?
At the Census 2011, Aboriginal and Torres Strait Islander peoples were estimated to comprise 3% of the total population; [7] and Aboriginal and Torres Strait Islander young people to comprise 5% of the total youth cohort (at the 2011 Census, Aboriginal and/or Torres Strait Islander individuals under 15 years of age comprised 35.8% of the total Aboriginal and Torres Strait Islander population, compared with 18.3% of the non-Indigenous population).[8]
As a general rule, and as supported by the data in Appendix 1, this position paper proposes a mental health needs index for Aboriginal and Torres Strait Islander peoples at least double that of the non-Indigenous population. In relation to specific mental health areas, actual needs indices would need to be determined.
This position paper therefore proposes the following as indicative equitable funding allocations from mainstream programs:
· For Aboriginal and Torres Strait Islander peoples as a total population: 6% (3% of population x 2 mental health and social and emotional wellbeing needs index); and
· For Aboriginal and Torres Strait Islander young people: 10% (5% of total youth cohort x 2 mental health and social and emotional wellbeing needs index).
Once an equitable allocation has been determined, the resultant share of mainstream MH&SEWB funds would be used as identified funds for Aboriginal and Torres Strait Islander-specific mental health and related programs and services.
For mainstream mental health programs that are demand driven, the identified equitable allocation share could be used as both an expenditure target on Aboriginal and Torres Strait Islander peoples and a monitoring and accountability tool, and identified shortfalls used to drive policy initiatives to rectify access and differential use of services.
It is also important to emphasise that this is not a competitive approach but rather to provide an indication of the proportion of the total allocation for a mainstream program that the Aboriginal and Torres Strait Islander population, given their size and level of need, ought to receive.
It is against the benchmarks assessed by such a process that the challenge of equity should be addressed. Clearly, if any given program or services are not funded in an equitable fashion to benefit Aboriginal and Torres Strait Islander peoples then the cutting of such programs should be questioned. If anything, the review provides an opportunity to re-direct funds from the mainstream to Aboriginal and Torres Strait Islander peoples to address inequity where it occurs.
4. The most efficient way to spend Aboriginal and Torres Strait Islander mental health dollars
Implementation of the above methodology requires the review to:
· Define an equitable share of funding from mainstream programs for Aboriginal and Torres Strait Islander peoples in any given context; and
· Determine the most efficient way of spending the identified share to produce the best return on investment in terms of access and quality of service.
We propose the following as parameters for assessing efficiency:
Measure / Examples of the efficient use of funds / Examples of the inefficient use of fundsPrevention v cure / · Programs that strengthen social and emotional wellbeing, including by building on cultural strengths
· Programs that build individual resilience.
· Programs that support families and community functioning
· Programs that address the determinants of mental health conditions and suicide in communities.
· Primary mental health care
· Mental health promotion
· Focus on children and young people / · Hospitalisation for preventable mental health and related conditions (i.e. that have gone undetected by primary mental health care)
· Programs that address mental health conditions or suicide after the event
· Programs that fail to address the causes of mental health conditions and suicide
· Programs that weaken community control or otherwise are not supported by the community
· Programs that are not culturally appropriate and therefore not used by further stress on cultural practices
Holistic v specific / · Integrated services that address many aspects of a person’s life including mental health issues – this is the philosophy underpinning the approach of the Aboriginal Community Controlled Health Services
· Programs that recognise the importance of addressing the Aboriginal and Torres Strait Islander mental health gap if the broader health gap is to close
· Programs delivered across sectors and governments / · Dealing with depression as a biomedical issue (i.e. with medication) and not addressing the causal factors
· Programs and services from government siloes
Population (community) focus v focus on individuals / · Community-wide programs with a preventative focus / · Focusing on individual biomedical interventions
Culturally competent v mainstream delivery / · Programs and services delivered by Aboriginal Community Controlled Health Services
· Programs delivered by mainstream service providers who are culturally competent / · Programs delivered by mainstream service providers without language ability or knowledge of the community they are serving
Broad multiple beneficial impacts v narrow impact / · Programs designed and delivered by a community can increase that community’s capacity for self-governance and otherwise help it address the determinants that undermine mental health and cause suicide
· Strengthening Aboriginal Community Controlled Health Services.
· Programs that train and employ Aboriginal and/or Torres Strait Islander people
· Programs that make communities safer by reducing substance use and violence
· Closing the wider health gap in addition to the mental health gap thus helping to achieve the COAG Closing the Gap Targets / · Programs and services that are imposed from outside the community
· Programs that employ people from outside a community
· Programs that draw on funding that otherwise could be used to deliver services through Aboriginal Community Controlled Services.
Spending on Aboriginal Community Controlled Health Services is efficient spending