Apart from some independent policy measures such as the control of firearms following the Port Arthur massacre, three decades of efforts to reduce suicide rates in Australia have largely failed.
Stressing its genuine commitment to structural reform, the federal government has promised $2.3 billion in funding for mental health and suicide prevention. These investments were guided by the Final Advice delivered by the Morrison government’s National Suicide Prevention Adviser and Taskforce appointed in 2019 to ‘drive a whole-of-government approach to suicide prevention that ensures prevention services reach Australians that need them.’ While slated as driving forward a ‘paradigm shift,’ sadly the rhetoric and promised funding obscure the fact that the underlying approach to investing in mental health and suicide prevention remains unchanged; an approach that has failed for more than three decades.
The Final Advice delivers a set of recommendations jarringly similar to a long list of previous reviews including the Burdekin Report, 1993; Not for service, 2005; Senate committee report: From crisis to community, 2006; The hidden toll: Suicide in Australia, 2010; Contributing Lives, Thriving Communities, 2014; and report of the Productivity Commission Inquiry, 2020. All were based on wide-ranging consultations with stakeholders. All have highlighted systemic failures of Australia’s mental health system and its tragic consequences. All have included recommendations to strengthen primary prevention and community-based services, ‘whole-of-government’ cooperation, the social determinants of mental ill-health and suicide, and research and data systems to track outcomes. All promote the role of lived experience in priority setting. All point out funding shortfalls. And all have led to announcements of a new national mental health or suicide prevention office, commission, council, taskforce, advisor, and/or strategic plan.
Guided by the Final Advice, the promised $2.3 billion investment is spread across 37 programs, services, and initiatives highlighting a fundamental misunderstanding about how to invest for impact. While investing a bit in a lot of things seems like a good idea and gives the impression of a commitment to change, insufficient investment in any of those things will likely fail to deliver real impact no matter how large the budget envelope. As an analogy, providing suboptimal doses of chemotherapy to people with cancer will not effectively treat cancer no matter how much is spent in delivering it. Having sufficient workforce underpins much of the ability to successfully implement many of the proposed initiatives outlined in the budget. In a Guardian podcast, Christine Morgan highlighted that the budget importantly included an increase in the number of nurses, psychologists, and allied health practitioners in mental health settings through provision of 1000 scholarships and clinical placements. Where did this number come from? Given it equates to 1.8 additional staff per local government area in Australia, is this enough? Where is the analysis and estimates of impact that underpin this and other investment decision?
Why has this well-trodden but flawed approach to investing in mental health services and suicide prevention prevailed over more than three decades? A clue lies in the complementary report to the Final Advice entitled, Shifting the Focus. This report draws on decades of research evidence and offers up a dizzying array of ‘risk and protective factors’ related to suicidal behaviour (85 of them on rough count) for governments and agencies to address. This promotes the idea that any effective response must be so comprehensive, all-encompassing, and long term as to render it infeasible and unaffordable, hence an over reliance on consultation and placation to inform investment decisions.
Shifting the Focus also provides a ‘decision tool’ to guide agencies in their response to suicide. Unfortunately, it consists of a checklist of 35 questions that simply reinforce complexity. It does not provide guidance on the best strategy for allocating resources, nor does it consider the impact that alternative strategies are likely to have on short or longer-term suicide rates. In this age of big data, and advanced computing and analytics, it is difficult to see this ‘decision tool’ as anything but rudimentary, and certainly not reflective of the quality science and decision analysis Australia is capable of. In contrast, as in many other fields (ie., economics, financial services, engineering, ecology, control of COVID-19 infection rates) informed simulation of the likely impacts of different options can help decision makes chose the best buys.
Systems modelling and simulation need not be the exclusive domain of scientists. To date, applications of this approach in regions of New South Wales have already demonstrated the benefit of an open, transparent, inclusive approach to the development of systems models. The approach can empower local communities to rally around those strategic responses that make the best use of available resources. Systems modelling can help to put an end to ‘persistent wasteful overlaps, yawning gaps in service provision, and limited accountability’ in the mental health sector.
After 30 years, we need to abandon the ‘comprehensive and all-encompassing’ rhetoric that has high levels of popular support but delivers low levels of impact. The question now is whether our state and national governments will squander the opportunity to lead real change by continuing down this well-travelled but fruitless path or shift gears to engage with new tools that point to highly targeted short and longer-term investments. When delivered at sufficient scale and intensity, it is those new investments that are most likely to deliver real impacts.