 Hello. My name is Ruth Beyn. I'm a psychiatrist by background and currently in the role of Deputy Chief Medical Officer with the Commonwealth and I'm absolutely thrilled to be giving this opening address to the Mental Health Professionals Network conference. Of course I'd like to start by acknowledging the traditional custodians of the lands on which we meet. For me it's the Wurundjeri people of the Kulin Nation and I pay my respects to their elders past, present and emerging and of course that extend that respect to any person of Aboriginal and Torres Strait Islander background who may be listening to this talk today. So I might bring up the slides now if we can. And the title of this conference was All Together Better, Collaborative Mental Health Care in a Changing World. So I'm going to talk a little bit about some of the changes that have been happening in my world and how they relate to collaborative care. Next slide, thank you. So look I'll talk very briefly about Australia's mental health system which we all live and breathe. I'll touch of course on most of the audience for this I'm assuming are people who work within health and who have a particular interest in mental health if not part of the mental health workforce. I'll then talk a bit about one of the things that's been occupying a lot of my time in recent months or even the last year or two which was the evaluation of better access which is a very significant chunk of Australia's mental health investment. Then touch on the agreement and then go to where to next. So next slide thanks. When we think about mental health in Australia it's hard not to remember the last two or three years and COVID and the impact that that may have had but even if we go pre-COVID we know that there were a lot of concerns about Australia's mental health system and about the mental health of Australians. Our system is made more complex because of our federation with different responsibilities being shared between the states and territories but before COVID and during COVID we had a number of really important bits of work and plans and reports that pointed out some of the issues in our system and also some of the levels of distress and anxiety and other mental health concerns that people in the community were experiencing and I have to say we as in the Commonwealth where I worked kept a very close eye during COVID on the number of calls going through to lifeline or kids helpline or reach out and they were all pretty worrying in their risers although of course they'd also recognise that people were reaching out for help. Next slide thank you very much. One of the very important pieces of work that was done amazingly was done during 2020-21 was the second national study of mental health and well-being and this is a really important study because it's carried out by trained interviewers using a standardised interview schedule that's capable of a reasonable assumption at diagnosis and really what it showed was that in many ways things hadn't changed since the last survey which was back in 2007 in that one in five Australians had experienced mental health disorder in the mental disorder in the previous 12 months. That was about the same but the thing that was particularly concerning was that 40 percent of young people had experienced that sort of problem in the previous 12 months. There were some particular groups that were at very high risk or more likely to so particularly women rather than men as I said young people rather than older and particularly 54 percent of people who identified as LGBTIQIA plus reported having experienced a mental disorder. So this survey provided a deeper understanding of the some of the challenges that have been faced by Australia. It also gave us some information on who was using which services, their social and economic circumstances and perhaps one of the positives if there is a positive out of this is that around about half of those who had experienced a mental disorder in the previous 12 months had sought support. Now half doesn't sound like a really great number but in fact that was significantly better than the 2007 results. So it's sort of it's hard to extrapolate cause and effect but but I think what we could say out of this is that people were we did have to have high levels of of mental distress most often mood anxiety people are by and large reaching out for help but there are significant parts of the population that seem to be experiencing higher levels of distress and may or may not be able to access that help. So next slide thank you very much. Just want to touch on the mental health workforce because when people reach out for help they most often will reach out to either support services or clinical services in both the private public state or Commonwealth funded sections and we hear a lot about workforce don't we are not just mental health workforce not even just the health workforce we hear a lot about challenges of getting the right people in the right place and certainly within mental health there are I'll come to it shortly but there are significant gaps in absolute numbers of of various professions as well as a maldistribution. So the whole sort of importance of supporting people and trying to improve workplace culture and improve the sort of recognition the person centered care and people feeling like they're doing a good job is pretty important perhaps just as an example of some of this we have a thing called the national mental health services planning framework which is a really useful tool to try and plot the type of workforce you might need for a given population and in 2019 according to that planning framework there was a 32% shortfall in mental health workers compared to the target and it was expected that that shortfall would increase if we didn't do something about it and the largest relative gaps were for consumer and carer workers now that that's it's a larger relative gap although it's a much smaller workforce and it's a growing workforce but also there was a shortage of psychologists as well as nurses and others next slide thank you very much so this just gives you a bit of a graphical sort of display of of where we've where we've got shortages I'm not sure if you can read that if it's too small for you but basically the top one shows is the general practitioners then psychiatrists then going down to registered nurses which is the biggest workforce but a very significant gap through psychology OT indigenous health workers and then the second big one is the vocationally qualified mental health worker again a really important part of our workforce providing support particularly in the community and probably particularly in relation to NDIS services so there's shortages but we also know during COVID that our workforce experienced quite significant distress and particularly psychological distress there was a quite there was an important survey that canvassed health care workers and from that I think about 62 percent reported experiencing anxiety during COVID 58 reported being burnt out feeling like they weren't bringing value to their work or they were you know just couldn't get the same enjoyment and satisfaction from their work and in particular I think that affected doctors and nurses who had increased rates of depression and suicidal ideation so there were also sorts of disruptions to workforce and all of those roster changes not only those people who had COVID but of course the impact of having to work in COVID affected environments one of the things that the department funded for workforce during that time was the essential network or 10 run by the Black Dog Institute and just to highlight that during from sort of May 2020 through to January 2023 there were almost 90,000 people who accessed 10 so that was health professionals looking at the resources and programs by the digital hubs as well as a very large number reaching out for assessment or even one-on-one support so people did did and maybe still are have a tough time working in health and not and mental health's included in that during the last two or three years so we've got we've got a difficult system we've got people who are experiencing high levels of distress and a workforce under pressure next slide thank you. So now I'm just going to move to it as I said one of the things that's been occupying a lot of my time better access people might might remember better access came in around about 2006 it might have been called better outcomes back then but but basically it was a it was a recognition by the Commonwealth Government that there was limited access to evidence-based treatment particularly again for anxiety and depression and that one of the ways of doing that would be to create an MBS funded system for a limited number of sessions for people to be able to access focused psychological strategies or other psychological therapies on referral from their general practice and over the years better access has changed a bit we of course had additional sessions in relation to some disasters like bushfires additional sessions were also created during COVID the the original six went up to 10 and then that went up to an additional tender in COVID they came to an end at the end of December along with the other COVID measures but but better access was certainly taken up and and in 2021 an evaluation was carried out looking at better access from a number of viewpoints I won't go into the detail of that evaluation it's it's available publicly but what that evaluation found was that in 2021 one in every 10 Australians received some better access service now that could be the mental health treatment plan provided by a general practitioner and around one in 20 received at least one session of psychological treatment which could have been delivered by a psychologist clinical psychologist OT social worker or of course a general practitioner but but while that says a lot some of the recent inquiries particularly the productivity commission which reported in 2020 said well how do we know that this is being targeted to the right groups how do we know whether it's having a good outcome or not clearly lots of people are using it but is it is it working and so that's was the other reason for really looking at getting this independent evaluation and as it says there that evaluation was published in release publicly in December 2022 it yeah just the next slide thank you sorry about that I'm so one of the the things that the better access evaluation did was that firstly it combined a number of databases so one of their studies enabled us to look across the population at linking people who'd used a better access MBS item with other things socioeconomic variables like place of address income use of other health health items and so forth we also were able to do some questionnaires of individual users of better access as well as surveys and questionnaires of those who provided better access it was a fairly large sort of consultative forum that happened with a whole range of providers consumers carers and others that that generated a number of ideas and as I said there was also sort of plotting out who was getting better access how much and with what apparent outcome and basically what the evaluation found was that those who did receive better access by and large said it was helpful and they had positive outcomes and in fact the more unwell a person was at the beginning of the the episode of care the greater the improvement and and that was found again and again but it also found that some parts of the population and some segments within the population were more likely to access better access and more likely to access more of better access than than others so people in regional rural remote areas those from lower socioeconomic areas by by postcode or modified non-ash area tended to be missing out either getting just a treatment plan and no psychological services or a fewer number of sessions and and the the evaluation also found that well better access was initially targeted towards those with if you like relatively uncomplicated presentations that over time that that had changed and people with quite severe quite complex needs were were accessing treatment through better access if they could get it but there were also of course a number of barriers for for getting access and particularly those were geography which I've already touched about but also affordability and again over time and this was really even more noticeable in the in the last 12 months so during 2021-22 the gap fee had actually increased in size and in the number of services where gap fee was charged and again that sort of says that this which is a it's a publicly funded psychological access to psychological services was in a sense being distorted to those areas where more practitioners were available but also where people were more likely to be able to afford and pay a gap fee and so that the the the work for shortages that I've just talked about were again getting a bit distorted by by where people were moving to provide services and and I think the the evaluation absolutely it sort of emphasised that better access is good but it's not equitable and and it's not equally available to across the population and one of the very interesting findings which is I'll just mention because it was fascinating to me is if you look at level of need as measured by something like the K-10 then overall within the population there are higher levels of need amongst those who if you like have lower socioeconomic profiles or who live in areas where there's greatest socioeconomic disadvantage those those people tended to have higher rates of prescribing of antidepressants and lower rates of access to psychological treatments now now there might be all sorts of reasons for that there's reasons of choice and availability and all that sort of stuff but it did feel like the more intensive and if you like time time investment that goes with psychological treatments was again being more available to people in in particular areas and not to others and I think this is demonstrated on this slide next slide thanks so look at this is a really neat graph as I've mentioned the greatest barrier to accessing better access probably was that affordability and and you can see there the price going up or the cost rather going up during 2022 and probably if we looked at why people in those lower socioeconomic areas were having fewer sessions it's not to do with severity it's probably to do with availability and affordability clearly the availability of telehealth changed some of this but but we all know that particularly for psychological treatments telehealth is of value but it's not the whole answer and it's not going to resolve the equity issues and and I think the number of newt the one of the other areas of concern was that with the extra 10 sessions those extra 10 sessions didn't seem to be going to people with more complex presentation at the beginning it seemed more likely that the extra sessions that you know up to 20 sessions were more likely to be going going to those who could afford rather than need and there also may have been a compounding factor there because the number of new people accessing better access treatment reduced from 56% in 2018 down to 50% in 2021 when those additional sessions were in place so you know I guess the conclusion from better access is people are using it it's great it's expanded I'm sure those who provide better access services are providing excellent care and and interventions but it certainly needs a bit of attention and a bit of reform if we're going to say that it is also about improving access across across the community and and targeting perhaps those with particular needs thanks very much next slide now along the along the other time the the better access evaluation was happening and COVID was happening and all of that we were also in the process of developing the national mental health and suicide prevention agreement this was again a really important piece of work and and again in response to a number of reports but most particularly the productivity commission inquiry and really again highlighting that there is great fragmentation that different jurisdictions do things differently that there's been confusion in roles and responsibility and and that if we're going to try and bring the system together more and make it both more accessible but also more easily navigated as well as address gaps then it can't be done by one level of government alone and and clearly this agreement which was a bit of a miracle I think that we managed to get get done and get all states and territories agreed but clearly it will take time and particularly again if we come back to workforce there's a pipeline things take a long time to get in place next slide thanks very much so just a few of the outcomes that we expect from the national agreement and clearly the government has changed it was the previous government that commenced and signed off that national agreement but my experience is that the momentum is continuing and that people continue to recognize the importance of this so I won't go through all of this but clearly some of the outcomes of the agreement were around better data better information sharing some about better and more standardized approaches to entry to the system through more consistent initial assessment a better articulation of the roles and responsibility and and trialing some new models of care and I might just go to that now so we'll go to the next slide thanks um when one of the recommendations from the better access evaluation was acknowledgement that a fee-for-service model doesn't it is it is you know it's great it's good in many circumstances but a fee-for-service model doesn't always allow the sort of supports and interventions that people who particularly who might present with more complex problems might need so one of the big emphasis in the agreement is some of the new models of care that are affordable that have a more multi-disciplinary workforce and and that are more easily accessible so some of these are just beginning some are some are sort of well established but i'm just going to talk through them a bit and there are three main streams if you like which I'll touch on the head to health kids which is probably a long overdue recognition of just how important it is for young young children and their families to be able to access mental health assessment and care the headspace which headspace has been around a long time but during COVID it became obvious that there were quite long wait lists in some places and real struggles in in attracting the right workforce and then head to health adults and as you can see in that slide the the common factors of these are that it's targeting towards not the ultra ultra acute or severe that are so you know that by and large receive treatment and care in the state funded systems but but do involve multi-disciplinary teams have a more holistic approach and not defined by narrow eligibility criteria thanks very much next slide so head to health and these these things are just at the beginning but we did have the opportunity to have a bit of an experiment with head to health because during COVID people might recall that Victoria had pop-up head to help clinics and they also were opened in ACT and New South Wales but we're and and for those of you who are in Victoria Victoria has a sort of different profile because Victoria as a result of the Royal Commission has announced and is developing a whole stack of local mental health and well-being centres that are very similar I think to the head to health model anyway we've already got we've already got nine of them and I'm actually went to the opening of one in Canberra at about mid-feb and I think just at the end of Feb I'm going to the opening of one down in Geelong so you know they're happening and the 21-22 budget announced funding for establishment and ongoing operation of a whole stack of of others dotted around the country and the the idea of these is that they're located in places that are easily accessible by their community that they can be accessed through ringing the central number 1-800-595-212 or by walking in and that they do provide a mixture of sort of if you like support and coordination nearly all of them will have a significant number of peer workers to provide that sort of welcome and support but also access to clinical treatment not not not intensive or forever because these things have to have throughput but much more flexibly driven and with a variable workforce and the funding model sort of allows for a degree of regional variation to address local needs and although you know I think these this model is still evolving to have a flexible workforce that will meet the needs so for example the one in Canberra that I went to recently had a couple of clinical psychologists part-time psychiatrist as well as I think I think an OT and I can't remember if there was a social worker and several peer workers as well and so so we're really you know able to respond to different needs but then and they also have I hope we'll all have very strong relationships with their state and territory funded service the one in Darwin is co-located with the top end acute mental health service run by the NT government the one in Canberra likewise has a really strong relationship with with with the local health service. Next slide thank you the the next model here just to touch on is the Head Health Kids Hub this is much much earlier days I think there's not one fully established fully open yet but but there are there are some that are on the way and there will be at least one in each jurisdiction I think the kids have each jurisdiction by 22-23 and ACT and in Northern Territory a little bit further behind I think they'll get theirs by 23-24 but again the idea is that these will complement that they'll integrate well with the state-funded maternal and child health services as well as child mental health services they'll they'll be able to offer assessments and as I said not predetermined by diagnosis these will need to be carefully watched because there's a lot of need out there and we know that there's not much point to have something that is not accessible or that you've got a six or 12 month waiting list for so these are again a very exciting model one that I'm really looking forward to keeping really close eye on next slide thank you and by the way if anyone can hear my dog streaking in the background they're not in pain if you can't hear them I'm very glad the the next one just to touch on is Headspace. Headspace has been around for a long time there's a lot of them I think there's 153 out there at the moment of which a significant number are located in rural and regional Australia and that it's very much a primary care model so Headspace was not intended to care for those with more complex presentations and for many in many places that that was a real gap that there was a threshold if you like for accessing adolescent mental health services funded through the state was quite high and Headspace struggled to to respond to that level of need so there is a at the moment a rollout of of an increase in the funding base for Headspace and the expectation of that is that it will now enable a stronger workforce that will help deal with some of those weight less problems and perhaps also be able to respond to people with with more complex needs although I'd sort of be very you know very important to emphasise Headspace is a primary health model there are of course a limited number of early youth psychosis services that are more intensive for particular subgroups of young people but but those then there are not so many of those so again this this intention is to enhance the more coordinated multi-disciplinary care for cohorts of young people and hopefully all of these services also provide a platform for students for graduates for people in early on in their career to be able to have exposure and work in order to grow the workforce as well as grow their experience so those are some of the things that's happening under the national agreement next slide things I also just wanted to sort of point out that we do look for what what other models are happening and what what sort of innovations or models of care are being developed because Australia is not not alone we may be an island but but we share many of the mental health pressures with with others so just to mention a couple there in the UK they're improving access to psychological therapies or IAT started quite a while ago now it's it's pretty extensive I'm sure there's criticisms of it but one of the things that IAT has done is really put in place a very robust measure for outcome reporting and and that enables people to compare and contrast outcomes over time and also across areas and and I think you know one of the things we don't have is is a sort of embedded outcome measurement in New Zealand it's relatively new the access and choice program and the model there is to actually place mental health practitioners clinicians and support workers within existing general practices and and again a really strong part of their model is that you'll get a same-day appointment and they they do a lot of sort of single session goal focused interventions but if you need more you can you can get more so they're really trying to have a strong focus on availability immediacy so opportunistic availability as well as a focus on being culturally and socially appropriate and then one of the things that's happening in Australia developed by Beyond Blue is a thing called new access which is it's effectively a sort of a mixture of face-to-face and online coaching to individuals who present with mostly sort of mild mild problems or particular life stresses or workplace stresses so I think it's important to recognise that there are other other things happening and I think the final slide thank you so to sort of round it up I I try very hard to remain an optimist in my career I have to say things go up and down a bit I mean they're quite sure if you're heading in the right direction but I do think hand on heart that we've we've got some really important bits of work that have been done that we can build on so better access being evaluated and now looking at what what either major changes or minor changes might need to be made to that to improve it I think of course that sits alongside some of the work in the strengthening Medicare area but through the agreement looking across state and territory and Commonwealth funded services and also how how funding models like how salaried services like the head to health platforms might fit alongside FIFA service MBS services is happening really I think acknowledging that sometimes multi-disciplinary care is important now that's not new I mean community mental health centres have always been multi-disciplinary but of course the over time their availability has narrowed and thresholds have become quite challenging so so trying to sort of loosen that up and I think you know as I said to use think about workforce all the way and think about balancing placements expanding people's interest in mental health and and really it's sort of thinking what is the right workforce and are we using people to the best of their skills and ability so I know reform will take time I'm sure we'll talk about many aspects of that during the mental health professionals network conference thank you again very much for inviting me to be part of it and I wish you a happy conference thank you goodbye