Commissions are a well-known means of addressing certain types of problems for governments and communities. Therefore it is a good idea to look at some of the reasoning behind Commissions generally when considering the role of the new NSW Mental Health Commission.
The main reason for setting up Commissions to deal with particular issues is that it is sometimes necessary to supplement ordinary government processes which have not succeeded in addressing well-understood and long-standing grievances, especially around inadequate resourcing. The area of mental health services and support for people living with a mental illness, their families and carers certainly falls into this category.
Generally speaking, Commissions don’t work unless a lot of people want them to work, but small size is not necessarily a fatal impediment for Commissions. If they are to succeed, they must have sufficient expert support and the engagement of key stakeholders (including building feedback from consumers and carers into the superstructure of the Commission and its mechanisms). “The stars must align, but so must the Departments” as one wag put it at a community forum. If Commissions do have this engagement, then they have the potential to make significant gains in addressing an issue like the adequacy of mental health and other support services. Commissions can help people to influence service design and delivery outside the hierarchical command and control systems of the health services themselves.
However, in order to succeed the Commission must have not just the support of stakeholders, but also be able to measure the quality of services and the quality of outcomes, and have ‘statutory levers’ (laws that make people cooperate) and access to government to get changes made. The practical role of Commissions also means collecting information about the services received, from both service providers and the people receiving those services.
The Bill to create the NSW Commission addresses the ‘statutory levers’ and the support of the federal and state Ministers for Mental Health (Ministers Butler and Humphries respectively) demonstrate access to government. The main areas which have not been clearly resolved by the Mental Health Commission Bill 2011, shortly to be debated in State Parliament; relate to:
the priority of its tasks and
the way in which the Commission is going to undertake these tasks, in particular how it will engage with stakeholders, in particular mental health consumers and carers to discharge them.
This is especially important given the very important role which seems intended for the Commission in driving reform of the mental health system, particularly through stakeholder engagement and other evidence based research. ARAFMI will be holding briefing sessions on the new Commission followed by consultations about how consumers and carers and other interested parties would like to be engaged by the Commission when it commences its work and to understand what they think should be its priorities
Functions in the NSW Mental Health Commission Bill 2011
The specific functions of the NSW Mental Health Commission are set out in the Mental Health Commission Bill in section 12 (1) which can be summarised as follows:
To prepare a draft strategic plan for mental health services for NSW for submission to the Minister;
To monitor and report on the implementation of the strategic plan;
To evaluate and report on mental health and other programs which effect people living with mental illness;
Promote the sharing of knowledge and research, innovation and policy development;
Promote prevention and early intervention,
Advocate for general health issues for consumers;
Promote community understanding to reduce stigma and discrimination.
The Bill supplements these functions in section 12 (2) by stating that the Commission is to;
Focus on ‘systemic issues’,
Take into account ‘co-morbid’ issues (such as physical disability and alcohol and other drug use),
Take into account interaction with the justice system,
Engage and consult with consumers, carers, service providers and NGO’s and CALD and ATSI groups.
The Commission can inquire into ‘any significant systemic issue affecting people who have a mental illness’ at the request of the Minister (section 13) or on the implementation of the strategic plan or any systemic issue it sees fit (after notifying the Minister (section 14)).
One of the key questions now to be answered is what priority should be given to these tasks?
The Minister for Mental Health (Hon Kevin Humphries) expanded on the Commission’s role in his speech to Parliament introducing the Bill on the 24th of November last year (2011):
“We heard also that the community wants a commission that takes a holistic approach to addressing the needs of people with mental illness across government and whole of life; has a broad scope in that it deals not only with mental health issues but also with a range of related diseases and disorders; focuses on systemic issues rather than duplicate the functions of existing entities that respond to individual cases or complaints; has a strategic capacity and leadership role with the ability to make recommendations about having a more integrated service system; has the ability to drive service quality improvement as well as report on performance; would be an authentic champion, maintaining strong ongoing connections with people touched by mental illness and other key stakeholders; and can educate us all about mental illness with the aim of stopping the stigma and, quite frankly, the discrimination that people affected by mental illness often experience.”
“Part 2 also deals with the commission's consultative structures... I point out at this time that the commission will be able to set up other consultative mechanisms as a means of building a bipartisan and broadly representative approach to mental health in the years to come. Related to this, clause 12 (2) provides that in exercising its functions the commission will engage and consult with people who have a mental illness, their family and carers, the government and non-government sectors, and the wider community. While the consultative mechanisms themselves do not need to be included in the bill, I shall speak about them at this point because they were forcefully recommended in the consultations and by the task force
“The commission will be able to establish working groups from time to time to ensure that it has access to a wide range of expertise and evidence in the performance of its functions, and that it considers the views of relevant stakeholders. Members of the working groups will be able to be drawn from the community, key stakeholders and other experts depending on the issue with which they will be tasked. The commission will also be able to conduct regular direct regional and community consultations to maintain those important connections with the community. This will help to ensure that the commission remains contemporary and relevant, as well as being fully informed of community priorities and the latest thinking about mental health.”
“The Government has made it clear in our original commitment to the commission, and also in NSW 2021, that we want to ensure that more adults and adolescents are diverted from the criminal justice system into treatment. Underpinning the central role that the commission will have in supporting the Government's reform agenda for mental health, the Minister will have powers under clause 13 to direct the commission to do a special report on a significant systemic issue. It is anticipated this power will be used when there are serious across-portfolio implications and the report would form the process of resolution through the Cabinet process.”
The Minister has provided further insight with his publication of a Newsletter, titled: “FURTHER UPDATE ON THE DEVELOPMENT OF A MENTAL HEALTH COMMISSION FOR NSW December 2011” (Available here: http://bit.ly/ybFBmt)
However, in spite of the many descriptions available the precise means and priorities for the Commission as it goes about its work is still being settled and commendably, the government is keen to do this in accordance with the views of stakeholders with emphasis on the opinions of consumers and carers. Much of the feedback received to date has been captured in the most recent available Report of the Taskforce to Establish the NSW Mental Health Commission Community and Key Stakeholder Consultations dated July-August 2011 (which can be viewed here: http://bit.ly/z0lmHb). As such, it is important to review these consultations and consider the practical implications of the kind of role they envisage in order to understand the direction the Commission is likely to take.
In summary, the Commission will not hold the budget for mental health services, but it will have some budget related functions. It will be required to review the expenditure of the mental health budget by health services to ensure; the right balance of funds for community based services is achieved; funds are targeted to need, and are results and outcomes focused; and more generally; that rural areas are supported appropriately; the needs and interests of people with lived experience of mental illness and carers are taken into account; NGO funding is considered and the budget for mental health services is expended in providing mental health services (‘quarantined’).“
It was decided not to have the Commission hold the budget for services because this would result in it replicating the administrative apparatus of the Health Department and because it would be less likely to be fiercely critical if required. The budgetary role currently envisaged is more like that of a community ‘auditor’, only with more systemic responsibility.
Practically speaking, this will require the Commission to have an understanding of:
The funding received by services,
The outcomes they achieve for the people they support and
How these services are experienced and perceived by the consumers and carers who use them.
This will required access to health service information about service delivery and engaging consumers and carers around their experience of services received (through a variety of means).
Most importantly, the Budget role that is envisaged for the Commissionwill give the Commissioner a role in protecting the mental health budget and ensuring this money is spent on mental health services. This could become an important issue as the new Commonwealth ‘efficient price’ funding model is introduced (read more here: http://bit.ly/AsrvjB).
“Service delivery Functions
The Commission will oversee quality assurance monitoring service delivery and outcomes. It will ensure best practice and standards are met. It may also have a role in brokering services and in promoting collaborative case coordination, as well as providing information to service providers and promoting evidence based practice. Other issues related to a role in brokering services and collaborative case coordination, as well as providing information to service providers. A view that the Commission should provide information particularly in relation to treatment location and availability was also strongly articulated.”
Also part of the ‘evaluate and report’ function in section 12(1), this quality assurance monitoring relates to getting value for money, but will also require that the Commission have strong access to health service information about service quality and service delivery practices. These are related as services must have adequate resources if they are to meet standards. However, this role also relates to identifying gaps in services and reforming them according to evidence and stakeholder experience.
Some areas of mental health already undertake regular benchmarking exercises. In these exercises various data, results and experiences of different services are discussed and compared to help improve services and to help services learn from each other’s experiences. These kinds of exercises generally appear to be very successful in driving improvements. The Commission could have some role in sponsoring these kinds of best practices across other areas of mental health where they are not already being employed. The best ways for engaging carers and consumers around experience of services will also need to be identified. Consumer and carer input is being sought to identify what would best suit most people.
However, the Commission’s service delivery functions will also require an understanding of the scale of unmet need for mental health services (that is, people who would benefit from using services who do not currently make use of them). This relates to another of the Commission’s functions: strategic planning
The issue raised about the Commission providing information about treatment location and availability is probably reflective of the high levels of unmet need for support in the mental health area, but better service directories and available advice as to the nearest and best means of accessing services (partially met at this time by services like ARAFMI’s and the Mental Health Association’s Information and Support Lines) would certainly be welcome.
The most decisive issue to emerge from consultations related to the Commission’s strategic capacity and ability to identify gaps in mental health services and in having some role in ensuring that services supporting the mentally ill and their carer’s are coordinated operate at a whole of government level.”
This will involve the Commission collecting information about the capacity and extent of current services, assessing the unmet need for services and the gaps between services, and then drafting a strategic plan to fill these gaps. This function is a clear priority as this (and subsequent monitoring and reporting) is the only specific task included in the legislation (section 12(1)). The New Zealand Mental Health Commission in particular has been very successful in mapping out the gaps it their mental health system and getting the government to address them with expanded services and funding.
Importantly, the Commission will also try to address gaps and cross-over between the work of different Departments and levels of government dealing with the same person. However, coordinating services, particularly across different Ministerial portfolios, is very difficult and often poorly done, which is why it has been identified as a priority area for reform. Mere access to the non-health data about services used by the mentally ill by other government departments is a significant legal, ethical and administrative challenge.
The Commission is given a ‘statutory lever’ to ask for this kind of information under section 16(3) and the other Departments cannot ‘unreasonably’ refuse under section 16(4). However, section 16(6) of the Mental Health Commission Bill will prevent the Commission from asking for ‘personal information as defined by Health Records and Information Privacy Act 2002 section 5 (see attachment below). While sharing information, even between researchers and data managers far removed from service delivery, should always be undertaken with great care and caution, it is not clear whether this blanket exclusion will complicate the strategic task of following the interaction of consumers with other agencies. The alternative might be to encourage all Departments to inquire and collect data about the mental health status of their clients, or to develop joint ‘identifiers’ for shared clients, although these may not be effective solutions in all cases; or preferable from a privacy perspective. What do you think?
“Stakeholder consultation & advocacy
Formalised and ongoing stakeholder consultation (to ensure) community engagement and direct involvement in the work of the Commission is vital to ensuring community confidence.”
As you will note from above, this function is necessary to support a range of the Commission’s other functions as well. The ways in which stakeholders can and should be engaged around the work of the Commission and in service feedback and improvement generally are a crucial part of the creation of “mechanisms to enable ongoing consultation”. Consultations are important aspects of advocacy as it is necessary to understand the experience of stakeholders in order to better represent them and to have services altered to better meet their needs.
There are a number of levels of engagement and involvement. The most general is feedback surveys on the experiences of services received, like the MHCopes Survey administered to consumers across NSW to measure their satisfaction and service experience. Similar surveys might be developed for other stakeholders. In addition, stakeholders could be asked to regularly provide feedback of a more general nature. A variety of mechanisms, such as online surveys and face-to-face focus groups will be required to allow for differences in availability, knowledge and interest. The Commission will likely need to develop a suite of approaches in order to be able to get feedback from community stakeholders.
More experienced stakeholders may also wish to act as formal representatives on Committees to provide their perspectives on a more ongoing basis. There is already an Advisory Council of stakeholders in the legislation to advise the Commissioners, but the Minister also refers to working groups of stakeholders that the Commission may wish to bring together for specific projects from time to time, and these bodies will also provide scope for consumer and carer representatives.
“Local and regional scope
In addition to the recommendation that the Commission have a whole-of-government focus, consultations revealed that the Commission should also address issues at the regional and local level. In doing so, it was recommended that the Commission should enable local strategies to deal with local needs.”
The problem of getting access to services in regional areas is a complicated and thorny one and the Commission will certainly need to address this as part of its strategic plan. This is an intrinsic part of the service gap analysis.
Establishing a proper evidencebase to enable and support best practice was seen as important during consultations. Across the consultative fora, stakeholders wanted the Commission to research and promote evidence based best practice. Similarly, respondents to the online survey strongly agreed that the Commission ensure methods of delivering mental health services are based on evidence.”
A mandate to promote research into evidence-based best practise could also be tied in with the Commission’s role in helping to ensure adherence to standards which are in turn based on evidence. It is not clear what the Commission’s role would be with regard to commissioning or sponsoring clinical research.
A role for the Commission in initiating educative campaigns was raised through the consultative forum process. In particular, educative campaigns to address and reduce stigma were identified as a priority. These aims were supported through the results of the online survey which agreed with the Commission working to improve community awareness and knowledge of mental illness and of the treatments available.”
Anti-stigma campaigns are important as is the general educative role of the Commission in de-mystifying mental illness.
Conclusion and Measures of Success
As you can see from the above, the Commission has a large number of functions and priorities. Clearly, one of the highest will be drafting the strategic plan, which entails identifying gaps in services and between services. It will also involve the need to hear from stakeholders about their experiences, both routinely and in more depth on occasion, which would make planning and laying the groundwork for consultations a high priority as well. After discharging these basic functions, the Commission will have a wide mandate to inquire into the sore points in mental health and will want to hear from consumers and carers as to what these might be.
What do you think the Commission’s objectives should be?Do you think it has the capacity to discharge its role as it is currently conceived?
Generally speaking, the measures of success for Commissions are:
Do community concerns get addressed effectively? and/or
Do they fall back off the radar?
In five years or so it will be interesting to review the progress made given the high hopes and strong support for the new Commission’s role.
In order to support the work of the new Mental Health Commission by researching the best ways of engaging people across the Community, ARAFMI will be holding briefing sessions on the new Commission followed by consultations about how consumers and carers and other interested parties would like to be engaged by the Commission when it commences its work and to understand what they think should be its priorities. To register to attend, click here: https://www.surveymonkey.com/s/MXPHDJ9
For a schedule of ARAFMI's Mental Health Commission presentations and consultations, clik on the file link below.