Australia's mental health commissions: evaluating a natural experiment

In September 2023, Minister for Health Mark Butler presented the findings of the investigation into the National Mental Health Commission.1 No evidence of fraud or maladministration was reported and no findings against any individuals were made. However, the report found the Commission plagued by high levels of organisational distress, low morale, and deep divisions.

It also found the Commission incapable of fulfilling its original mandate in relation to accountability for mental health. It lacked key strategic and technical skills to develop and publish its promised National Mental Health Report Card and was operating without strategic or operational work plans.

This finding raises questions about not just the National Mental Health Commission, but mental health commissions across all Australian jurisdictions.

Over the past decade, Australia has embarked on something of a natural experiment. Across our nine state and federal governments, only Tasmania and the Northern Territory have resisted the temptation to establish a commission‐type body in mental health. The concept of a mental health commission originated overseas at the turn of this century, with reference to a model operating in New Zealand,2 and posited that this kind of mission‐focused administrative structure could give fresh impetus to Australian mental health reform and oversight at both the national and state level.

Different models of commission were canvassed.3 Proponents of commissions tended to couch their advocacy in terms such as “independence” and “teeth”, referring to the legislative or other powers these new bodies would be able to exercise.

In all locations bar Western Australia, the commissions are entirely new organisations. Several models emerged, but in short, there are three: fund holder, strategic partner, and complaints manager (Box 1). In Western Australia, their commission is essentially a rebranding of the mental health branch of the WA Department of Health. WA's is the only Australian commission that holds the budget for direct delivery of mental health services. All the other commissions do not hold the budget for services, instead relying on strategic influence with other agencies to design reform. The third model is that originally adopted by Victoria, which identified opportunities for reform by seeking and analysing individual complaints.

A set of possible criteria was developed by which to assess their impact.4 Rudimentarily, it was suggested that successful commissions should show evidence of better resources, services, accountability, and stakeholder engagement.

A distinguishing feature of all the commissions, and one not addressed by the recent review of the National Mental Health Commission,1 is how little is understood about their performance. The Minister's federal review was spurred by concerns about maladministration rather than to deliver a fuller evaluation of performance. The Victorian model was revamped as part of the Royal Commission into mental health undertaken in 2021.5 The South Australian model lapsed under one government to be reborn under another.6 A five‐year review of the NSW commission is part of its establishing legislation. Its 2018 review found that this commission had met its obligations under its legislation, but also suggested its role had become “less relevant and effective”, and that it needed to refocus around performance monitoring and accountability.7 A similar statutory review was undertaken in Queensland in 2019.8 A mid‐term review of the Australian Capital Territory Office for Mental Health and Wellbeing was undertaken by the ACT Government itself, rather than independently.9

Overall, Australia's experiment with mental health commissions remains unevaluated, with one exception. In 2019, the WA Auditor General tabled an evaluation of the extent to which the mental health commission in that state had met its objectives since its inception in 2010.10 Perhaps unwisely, the WA commission had been quite explicit in stating its goals. Despite significant problems in piecing together the requisite data, the Auditor General was eventually able to report that the proportion of hospital‐based care in WA had increased from 42% to 47%, further away from the target 29% spend the WA commission had hoped to achieve by the end of 2025. It also reported that the proportion of funding towards community treatment services remained the same at 43% but that the proportion of funding for both prevention and community support had decreased instead of steadily increasing (3% to 1%, and 8% to 5%, respectively). Key markers were heading in the wrong direction. Still, at least there were markers.

In the absence of similar, independent, formal evaluations, we have pieced together a picture of at least one of the original evaluation criteria — resourcing. Box 2 indicates that only the two smallest jurisdictions — the ACT and the NT — showed a faster rate of growth in mental health spending than in total health spending. For example, while mental health spending grew by just over 58% between 2010–11 and 2020–21 in the ACT, overall health spending increased by 47.4%. In all the larger jurisdictions and the federal government, growth in mental health spending was outstripped by growth in total health spending. For example, over the period, total health spending in NSW increased by 35.5% but for mental health specifically, only by 22.4%. Box 3 summarises this trend showing, for example, that mental health's share of total health spending in NSW declined by just under 9.7% over the period,12 while the ACT and NT increased the share allocated to mental health. These data suggest that commissions have struggled to deliver more resources to mental health.

All the commissions bar WA are small agencies, with annual budgets of less than $10 million. Australia is now spending $11.5 billion annually on mental health services.11 Total spending on mental health commissions is likely to amount to no more than $50 million (excluding WA), meaning system oversight currently garners less than 1% of total mental health spending. The relatively meagre resources make it difficult for commissions that rely on influencing much larger government agencies (such as health departments) and other players to change what they fund or how they work.

It is unreasonable to lay all the blame for stalled progress on mental health reform entirely at the feet of the mental health commissions, and in the absence of formal evaluations, the data presented here provide only a limited view. On the positive side, there is some evidence suggesting that commissions have given some more prominence to the role of lived experience in mental health services.1

However, accountability has been at the heart of Australian mental health reform since 1992.13 Commissions were supposed to address and give impetus to new reform. There is little evidence so far to suggest they have made much material impact. Even where a formal evaluation of a commission does occur, as conducted by the Auditor General in WA, the findings show retreat from stated goals and targets, not progress.

Commissions have often focused on the development of some form of report card, but the task of creating genuine and useful accountability in mental health far exceeds this. It requires building a whole process of systemic quality improvement, helping regional mental health planners and services to do better, by addressing four key questions of leadership, quality and efficiency:14

• Do you know how good you are?
• Do you know where you stand relative to the best?
• Do you know where the variation exists, and is it reasonable?
• Do you know the rate of improvement over time?

Properly constituted and equipped commissions may still play a role in driving better accountability in mental health in Australia. But if they are not equipped to answer these questions, what are they doing?