2016-02-16
Senator RICE: I wanted to begin with a noting in the MYEFO documentation under the section on mental health streamlining. This is anticipated to bring in savings of $141 million over the forward estimates. I am interested in some detail about exactly what the government is planning to achieve these savings. Can we start with that?
"It's a budget cut" - after the #NMHR response, govt cuts $57 million from #mentalhealth funding. #estimates pic.twitter.com/RmZMJWPHK1— Janet Rice (@janet_rice) February 10, 2016
Mr Cormack: That measure is made up predominantly of out-year funding in two major program areas that are transitioning into the NDIS. The $141 million is largely comprised of unallocated future growth funding in the Partners in Recovery program as it transitions into the NDIS. It is money that had not been allocated. There were no service commitments or no service development planned. It was money sitting there. Also, the day-to-day living and also a small measure which had come to its conclusion, which is the National Perinatal Depression Initiative, a national partnership agreement which concluded in June 2015. They are the essential components of the $141 million measure that results from streamlining of programs.
Senator RICE: Is this $141 million saving being reallocated into other mental health programs?
Mr Cormack: The $141 million is a save. It was made up as I have described. All of the mental health investments are a combination of money that is already in the system plus some additional funding in relation to Aboriginal specific mental health service programs. There is some new funding of the order of $84 million. Without getting into another program area specifically, part of the additional funding under the ice package also has a specific target in that area. It is also new money that is going in many ways to sit alongside some of the mental health funding.
Senator RICE: I am not following, sorry. So, that $141 million is not being allocated into other mental health programs; is that what you are saying?
Mr Cormack: I just need to clarify the question. Are you talking about the $141 million over four years?
Senator RICE: Yes. It was identified in MYEFO as savings from mental health streamlining.
Mr Cormack: That is right. That is as I have outlined it.
Senator RICE: Was that $141 million being reallocated into other mental health programs?
Mr Cormack: No.
Senator RICE: I am wondering how this is consistent with the government's commitment at the time of responding to the National Mental Health Review that funding for mental health would be maintained? We certainly understand there was not any extra money but that mental health funding would be maintained.
Mr Cormack: There actually was extra money. There was $84 million.
Senator RICE: You are adding $84 million and you are losing $141 million. That is a loss of funding.
Mr Cormack: It is money that had not been committed. It is money that was not supporting services. It was in the out years and, as I mentioned, also within the government's response to the ice taskforce final report there is additional funding that supports that area as well. I am happy to go through the government's response to the National Mental Health Commission line by line, but I have outlined for you that $141 million save. That is really all I can say.
Senator RICE: Yes. What you have clarified is that the $141 million is going into other programs that are not mental health programs, with the extra $84 million that is going into mental health. So, overall, over the forward estimates we have got $57 million less being spent on mental health programs.
Mr Cormack: The money has not been spent.
Senator RICE: No, but it was allocated.
Mr Cormack: Yes.
Senator RICE: It was supposed to be allocated.
Mr Cormack: I think I have outlined where that $141 million comes from.
Senator GALLAGHER: It is a budget cut.
Senator RICE: Yes.
Mr Cormack: I cannot be any clearer than that.
Senator RICE: We have had some discussion about primary health networks in general. The government has indicated there will be key performance indicators attached to primary health networks to measure the impact that their commissioned services have on mental health and suicide prevention in their respective regions. Have these KPIs been developed yet?
Mr Cormack: Yes, a number of KPIs have been developed. I will just find that. There is a three-level performance framework for PHNs. At the highest level there are population indicators. There are also organisational level indicators. There are four specific headline national indicators. One is potentially preventable hospitalisations. The second is childhood immunisation rates. Thirdly, cancer screening rates and mental health treatment rates. They are the national-level indicators. We also have a series of local indicators. These will be progressively developed with the PHNs through our formal planning processes. As I alluded to, we then have organisational indicators which are around governance, financial management, stakeholder management and the delivery of contracted, commissioned and direct services.
Senator RICE: So, the national indicators have been identified.
Mr Cormack: That is right.
Senator RICE: Did you say that the indicators for each of the PHNs are under development?
Mr Cormack: At the local level, yes. We are just working through those with the PHNs at the moment.
Senator RICE: Are they not completed yet?
Mr Cormack: They are not finalised yet.
Senator RICE: When will they be finalised?
Mr Cormack: They will be finalised over the course of the agreement with the PHNs. What we are trying to do with all of these, particularly the national indicators and the local indicators, is trying to draw upon existing national datasets. We had the AIHW in here before. As you would know if you are familiar with those reports, many of those measures are taken once every two years. Some might be taken annually and some more frequently. Generally speaking, those sorts of indicators are taken at a point in time.
Senator RICE: That is the actual data that you need.
Mr Cormack: That is right.
Senator RICE: The indicators do not need the data—
Mr Cormack: The point of the framework is that it is a performance framework. What we are doing through this policy measure is holding the PHNs to account for performance against those indicators. We need to make sure the data is right. We need to make sure the data is available, and we need to make sure that its measurement occurs within the time for which they are responsible for achieving the outcomes against which they are being measured.
Senator RICE: When will the PHNs indicators be finalised?
Mr Cormack: Broadly speaking, we have finalised the national indicators. So, we have. We have finalised the organisational indicators, and we have a list of indicators at the local level that are—
Senator RICE: Are they for the PHNs?
Mr Cormack: That is right. They are a subset of existing national indicators that are readily available and we will be populating that into their performance agreement. That is work in progress.
Senator RICE: When will that occur?
Mr Cormack: By July.
Senator RICE: When are the PHNs commissioning services?
Mr Cormack: July is the commencement date for commissioning. This current year is the transition year and they are required to undertake their assessment—
Senator RICE: Will they have their finalised set of indicators before they begin commissioning services?
Mr Cormack: They will and they will also have a commissioning plan, which is based on their population needs analysis. That will be completed before the end of this financial year.
Senator RICE: Will these indicators be made public?
Mr Cormack: We would certainly encourage the publication of those sorts of indicators. It is public expenditure. We work with the sector to develop those indicators. Certainly, they should be made available. Indeed, a number of them are already made available through the My Community reports and those sorts of things.
Senator RICE: What is the process to hold the PHNs accountable to those indicators?
Mr Cormack: They have a funding agreement with us. There are a number of schedules to those funding agreements. Their payments and their performance are related to achievement of the specific elements.
Senator RICE: You are holding the purse strings. Is there community input into the development of those indicators at the PHN level?
Mr Cormack: Most of the indicators are already available. They are not new indicators in the main. That is the essence of making them meaningful; not to come up with a whole range of new indicators but to work with the existing—
Senator RICE: Will they be the same indicators for each PHN?
Mr Cormack: That is right. Yes, that is the plan. Certainly, the national indicators and the organisational indicators, which are already settled, are the same for all of them.
Senator RICE: Yes.
Mr Cormack: The local indicators we will be settling with them between now and July. We would apply the same principle.
Senator RICE: Will there be a uniform set of indicators across all of the PHNs?
Mr Cormack: That is right.
Senator RICE: Is there stakeholder involvement in the development of those indicators?
Mr Cormack: The indicators are already developed. The indicators are nationally available indicators.
Senator RICE: You just said the indicators for the PHNs will not be finalised until July.
Mr Cormack: Yes.
Senator RICE: Yes, so there is a process of finalising them now.
Mr Cormack: Yes.
Senator RICE: I am just wondering what the stakeholder involvement in that—
Mr Cormack: We will be working with the PHNs—
Senator RICE: They are obviously critical in terms of exactly what the outcomes are going to be.
Mr Cormack: We will be working with the PHNs to finalise the choice of those indicators that would be applied to their local indicators.
Senator RICE: Will they have a subset of indicators for each region?
Mr Cormack: That is right, yes.
Senator RICE: I am interested in your thoughts about there being a lot of pressure on the PHNs in their first year of existence to develop multiple large scale outcomes. They have already been confirmed to be getting $350 million for mental health and suicide prevention in the government response to the MHC review and hundreds of millions of dollars more for drug and alcohol interventions and solutions in response to the National Ice Taskforce report. Given they already have this funding, does the department expect the new PHNs to be able to meet these high expectations and are they currently on track to meet them?
Mr Cormack: We are certainly investing a lot in capacity building, as I said earlier in response to an answer from Senator Gallagher. A number of these organisations have already got a good track record in commissioning. We are conscious that this is a significant change, but we are also investing in capacity building and we are confident that the PHNs will be able to take on this new commissioning role and over time they will get better and better at it. It is a big new change.
Senator RICE: It certainly is. I know there is a lot of uncertainty in the community as to whether the PHNs are going to be able to deliver. The government response to the NMHC review decided not to include Better Access within the flexible funding pool for PHNs. Why was better access not included?
Mr Cormack: Better Access is a well-established program. It is a demand driven program and it is certainly able to provide good access at a local level. I think it was described in some of the working papers as a workhorse in many ways of the primary mental healthcare sector. It is certainly not part of the flexible funding pooling arrangements that we have established. Over time, particularly when we look at integrated care for people with severe, chronic and complex conditions we will certainly be starting to look at for that group in particular whether the episodic nature of Better Access for that very complex chronic group is the best way to meet their needs. I hasten to avoid the use of the word 'pilot', but we will be looking at some demonstration sites where some of the PHNs have well-established integrated care models particularly for people with severe, complex mental health conditions for which a notional cap of 10 sessions a year may simply not be enough.
Senator RICE: Yes, it hardly touches the sides.
Mr Cormack: That is exactly right. We are looking at that. The other element of the government's response is also to look at the other end of the spectrum of people with mental health conditions and look to whether there is a lighter touch or a more accessible treatment pathway for those people. One of the core elements of the government's response is the digital mental health gateway. We have good evidence that that is an accessible treatment modality for many people. In some cases, it may well be more accessible, more available and more cost effective than a Better Access-type arrangement for that group. We will look at it over time.
Senator RICE: What particular analysis or criteria did you use to determine that Better Access should not be included? You said generally that you made that decision. Did you have particular analysis or criteria that you used?
Mr Cormack: The government's response was informed by a lot of stakeholder input and engagement. We have had a look at that particular program. We have identified intersection points—and I have just outlined them for you—at the very high end of need and also at the low end of need. At this stage, the Better Access program is a well-targeted program that is delivering services to most who need it in the main. There are a number of consumers who are not able to access that service simply due to the lack of availability of practitioner and in some cases there may be an affordability issue.
Senator RICE: In particular, I understand the data shows that it is not effectively servicing rural and regional areas. Did you do any modelling on the difference of impacts on the inclusion or exclusion of Better Access on different geographic localities?
Mr Cormack: No, we did not do modelling, but we consulted. We took on board a lot of expert input and, indeed, I think the core information source we were working from was the National Mental Health Commission's report itself. We recognise that some consumers are not well served by the current arrangements. We will need to look at other arrangements for those. The government also has other programs that support people in rural and remote areas as well.
Senator RICE: They are conducting population studies to determine the need in the area?
Mr Cormack: That is right.
Senator RICE: That will determine what mental health programs are commissioned. Has there been any analysis whether Better Access is meeting or is appropriate for the population needs of their area?
Mr Cormack: We have not commissioned that sort of work, but I am certainly aware that some PHNs independently are undertaking that local analysis and local research. Western Sydney is a good example. The PHN there has had a good look at a potentially better service model for people with chronic and complex mental health conditions. They have had a look at whether the Better Access arrangements are servicing the needs. We will certainly work closely with PHNs who have good ideas to see if we can make any use of the flexibility that we now have. I think one of the important points in the government's response is that we have moved away from centrally delivered, fixed program structures down to more flexible regionally focused and tailored programs where there is much more funding flexibility to match and align with the needs of the individual consumer rather than the consumer having to fit in with the program structures that we already have in place.
Senator RICE: Has there been a comparison of the cost-effectiveness of Better Access in relation to other mental health programs, such as the access to Allied Psychological Services, Mental Health Services in Rural and Remote Areas or the Mental Health Nurse Incentive Program?
Mr Cormack: I will need to just have a look at any work that may have been done in that. There is nothing at front of mind. We are aware that each program has its strengths and has its weaknesses. Any program that is dependent upon an individual practitioner and where they choose to work and live being the principal means of drawing down the program benefit for the individual obviously has benefits if you are in a well-serviced area and has shortcomings if you are in a regional and rural area. We are conscious of those sorts of features.
Senator RICE: You talked about the digital programs. I am interested in the new mental health gateway. When will the new mental health gateway begin?
Mr Cormack: We have already started the planning work on that. We have approximately 20 organisations that are funded by the Commonwealth to provide a range of telephone or web based services for people with mental health information needs or service needs. The first phase will be to work with those existing providers to identify where there are opportunities to consolidate some of the back end functions, particularly some of the call centre functions. We are working with those groups. That would pretty much be the first phase. Then we will look at a more significant rollout over the next two years, consistent with decisions by government in relation to the funding profiles for all four mental health services and other services. That is work that is underway at the moment.
Senator RICE: Are you planning for there to be a tender process for the mental health gateway?
Mr Cormack: We are doing some scoping work at the moment to shape what the gateway would look like. It would certainly be envisaged that, if there is going to be a significant change to the way those services are funded and configured—and there will be—we will certainly need to approach the market.
Senator RICE: Is it intended to roll up all of the other digital health services that are currently—
Mr Cormack: What we are looking at doing is looking across the suite of programs that we have got to look at ways of making it simpler for the consumer where a consumer may struggle to be able to find exactly which service to go to for their particular need. We have a lot of general entry points. We also have a number of very specific niche services. We are trying to make it a more integrated user-friendly service where the consumer is not left to have to make a choice of six or seven different entry points, so that there can be an easy entry point from that system.
Senator RICE: But do you not yet know whether it is one entry point or a number of entry points?
Mr Cormack: The policy objective is to create a digital mental health gateway, which will be an integrated, modern, contemporary interface for people accessing the service. It will invariably result in consolidation of many of those services.
Senator RICE: What was the time line, again? When are you having your consultation?
Mr Cormack: We are doing initial work at the moment to identify some early opportunities for consolidation. We will then do more detailed planning work for the subsequent stages. We will be wanting to have the gateway well and truly rolled out over the coming 12, 18, 24 months. There will be different elements being rolled out.