How to make good on a mental health promise

Last year the panel for the Mental Health and Addictions Inquiry met with 2600 people in public meetings and processed more than 5200 submissions from people in all sectors of society including those affected, their families, those working in the field and experts.

This strong response signalled the high level of public concern about our current approaches to mental health and addictions. People want things to change.

On June 4, the day before the Budget, the Government announced an investment of $1.9 billion to turn the sector around.

This is undoubtedly a big commitment, but big commitments have been made in mental health before.

For example, in 1995 Judge Ken Mason led an inquiry into mental health which led to a number of important initiatives including the setting up of a Mental Health Commission.

However, the old Commission had its problems. While it advanced our appreciation of recovery, it focused narrowly on the 3 percent of our population with serious mental health issues and missed out on the broader possible contributions from primary, community and public health, as well as virtually ignoring what was needed with addictions.

The old commission operated for only six years before Jenny Shipley’s cabinet opted to shrink it to a branch of the Office of the Health and Disability Commissioner, effectively neutralising its potential for change.

Interestingly, other commissions with a health focus have had similar struggles with survival. For example, in 1993 an independent Public Health Commission was formed to oversee improvements to public health services but, following the release of a series of reports regarding poverty, alcohol and tobacco, it only managed to survive three years. David Skegg’s recent book on the demise of the Public Health Commission, The Health of the People, points to a combination of alcohol industry interests and the discomfort of politicians with the commission’s recommendations.

For a commission to make a real difference, for it to hold government agencies to account and act as a circuit breaker leading to a paradigm shift in how things are done, will certainly take more than three or six years. Health services are complex systems with lots of moving parts. Durable change requires sustained efforts for a long time, more in the region of one or two decades.

So, for this investment to make a real difference, the new commission would need to be positioned in a way that guarantees its survival. But how might its independence and durability be protected over the next couple of decades? Lately I’ve been thinking over four possibilities, each of which has strong and weak points.

First, it could report, like the old commission, to a particular minister, say the Minister of Health. The drawback here is this line of accountability risks gradually turning the commission into part of the operations of that Ministry which could, over time, convert it into a public relations division thereby reinforcing a business-as-usual approach.

A second option might have the commission reporting to two or three ministers, perhaps via an interdepartmental committee. This has the advantage of coordinating efforts across several relevant areas such as health, justice and education. But cross-ministry initiatives have a reputation for becoming bogged down in turf wars between both ministers and ministries, and more controversial recommendations could end up buried in conflict.

A third option might have the commission reporting to a centrally powerful agency such as the Department of Prime Minister and Cabinet as occurs currently with the Child Wellbeing and Poverty Reduction Group. The advantage here is the capacity of the Prime Minister to knock ministerial heads together to urge cooperation on joint initiatives. However, this would only work with a leader who is committed to its objectives and could easily disintegrate under a Prime Minister with other priorities.

A fourth option might involve the Commission reporting straight to Parliament, along the lines of the Office of the Ombudsman and the Commissioner for the Environment. This has the advantage of distancing it from the vagaries of ministers, ministries and Cabinet, and for this reason, in my opinion, it is the arrangement most likely to ensure its survival.

Other options or combination of options might be considered and it is still uncertain which way the Government will lean. What is certain is the need. For the new Commission to successfully lead a transformation in how we handle mental health and addiction, it will need to survive and maintain its independence well beyond six years and find ways to guard against threats in a changeable and often hostile political environment.