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The Final Report of the Royal Commission into Victoria’s Mental Health System has been released

Michael Gorton AM and Matthew Goessler

“The narrative around mental health seems to repeat the same message – ‘don’t be afraid to ask for help’. The problem comes when you ask, there doesn’t appear to be any answer” – Witness Statement of Amelia Morris, 29 June 2019, para. 20

“An often-repeated explanation is that the system has ‘cracks’ and that people will fall through them. I don’t know if [we were] just unlucky to continually step on those cracks, or if the cracks are so wide that you cannot avoid them” – Anonymous 404, Submission to the RCVMHS: SUB.0002.0028.0238, 2019, p. 1

Most Victorians will at some point in their life experience poor mental health or mental illness, whether this be directly, or indirectly through someone we care about. One in five Victorians will experience mental illness each year, and almost half of Victorians will experience mental illness during their life. Despite the number of people who experience mental illness in Victoria, only about half receive treatment. Good mental health and wellbeing have been a low priority of governments and the community.

On 22 February 2019, the Governor of Victoria formally set up the Royal Commission into Victoria’s Mental Health System (the Commission). Just over two years later, the Commission has yesterday(2 March 2021) delivered its Final Report (the Report) addressing Victoria’s mental health crisis. During this time thousands of Victorians have engaged with, been consulted by and offered evidence to the Commission. With an emphasis on the lived experience of Victorians, the final recommendations offered by the Commission focus on paving the way for a new holistic approach to mental health.


The Commission was directed to inquire into and report on a range of matters contained in the terms of reference. These included:

  1. How to most effectively prevent mental illness and suicide, and support people to recover from mental illness, early in life, early in illness and early in episode, through Victoria’s mental health system, and in close partnership with other services?
  2. How to deliver the best mental health outcomes and improve access to and the navigation of Victoria’s mental health system for people of all ages?
  3. How to best support the needs of family members and carers of people living with mental illness?
  4. How to improve mental health outcomes for those in the Victorian community, especially those at greater risk of experiencing poor mental health including from Aboriginal and Torres Strait Islander backgrounds, living with a mental illness, from rural and regional communities and in contact with the forensic mental health system and justice system.
  5. How to best support those in Victorian community who are living with both mental illness and problematic alcohol and drug use, including through evidence-based harm minimisation approaches.

The Commission was also directed to establish an Expert Advisory Committee (the Committee) to be chaired by Professor Patrick McGorry AO. The Committee was to be consulted on:

  1. Engagement strategies to inform the conduct of the inquiry;
  2. Opportunities to most effectively raise awareness of mental health as an issue, challenge stigma and reduce discrimination associated with mental illness; and
  3. The likely impact of the Commission’s findings and recommendations on access, experience, safety and quality from the perspectives of people with lived experience and the mental health workforce.

Between 18 April and 5 July 2019, the Commission invited Victorians to share their experiences, views and ideas on how to improve Victoria’s mental health system. The Commission received more than 3,200 submissions from organisations and individuals during this period.

In July 2019, the Commission conducted nineteen days of public hearings during which it collected evidence about Victoria’s Mental Health System. The Commission heard from witnesses on issues relevant to the terms of reference including stigma; carers and family; suicide prevention; LGBTIQ+, and culturally and linguistically diverse communities; and community resilience. Further public hearings were planned for April 2020, but were cancelled due to the impacts of the coronavirus pandemic.

In addition to hearings and submissions, the Commission held more than 60 consultations across Victoria in April and May 2019. Around 1,600 people attended these consultations.

Throughout the Commission’s consultation and research, several major themes became clear. These themes formed the basis upon which the Commission made its final recommendations. Notable observations of the Commission included:

Demand has overtaken capacity

The Victorian mental health system is overwhelmed and cannot keep up with the demand for people looking for treatment, care and support.

Community based services are undersupplied

There is a large difference between the actual number of people receiving specialist mental health services and the actual consumer-related community service hours delivered

The system relies too heavily on medication

Too often services rely on medication as the main, or sometimes only, treatment people can receive. There is not enough focus on therapeutic interventions and recover-centred treatment, care and support.

Getting help is difficult

People struggle to access the services they need.

Access to services is not fair

Poverty and disadvantage make it even more difficult for people to access services

The system is driven by crisis

Due to limited services, many people only receive treatment, care and support when they are in crisis.

Families, carers and supports are left out

There are around 60,000 Victorians who care for someone living with a mental illness. These people are often left out of consultation that would help them in their caring role.

There is a lack of focus on promoting good mental health and wellbeing

Victoria has a higher ‘burden of disease’ (effect of poor mental health on the population) than most other Australian states and territories. More opportunities need to be taken to promote good mental health and wellbeing

There is not enough focus on the early years

The system is slow to meet the mental health and wellbeing needs of infants and children under the age of 12

Younger people are negatively effected

A substantial proportion of lifetime cases of anxiety, mood, impulse control and substance use disorders appear by the age of 24. There is a strong case for investing in the mental health and wellbeing of young people

Trauma is unseen

The system needs to provide more holistic approaches and be more responsive to trauma.

The focus on personal recovery needs to be strengthened

The current system focusses on the goal of ‘clinical recovery’ or how much a person’s symptoms have decreased. The focus needs to be on ‘personal recovery’ or being able to create a meaningful life with or without mental health challenges

Culturally safe services are not always available to Aboriginal communities in Victoria

Depression and anxiety is more common among Aboriginal Victorians than among non-Aboriginal Victorians for a host of reasons.

Some groups face further barriers

Aboriginal people, LGBTIQ+ people, refugees, asylum seekers, people from culturally diverse backgrounds and people living with disability face a range of barriers when seeking treatment, care and support

The system’s foundations need to change

Structural issues have contributed to a system that is uncoordinated with large service gaps

Dignity is ignored and human rights are violated

Restrictive practices and compulsory treatment are often used

The workforce is under-resourced

The mental health workforce suffers serious shortages, particularly in some specialties and in rural or regional areas

The system is outdated

The mental health system has not kept up with people’s changing needs for up-to-date treatment, care and support. The system does not encourage innovation

The Interim Report

In November 2019, the Commission delivered an Interim Report outlining a number of priority recommendations that addressed immediate needs and laid the foundations for a new approach to mental health.

The Interim Report took stock on what the Commission had heard to date, and made several interim recommendations. Some of these recommendations were aimed at specific, immediate deficiencies in Victoria’s mental health and wellbeing system. Others laid the groundwork for more fundamental structural changes needed to transform the state’s mental health system.

In summary, the Commission recommended:

  • Establishing a new entity, the Victorian Collaborative Centre for Mental Health and Wellbeing;
  • Expanding youth and adult acute mental health beds to relieve critical demand pressures;
  • Expanding follow-up support for people after a suicide attempt by recurrently funding all area mental health services to offer the Hospital Outreach Post-suicidal after Engagement (HOPE) program;
  • Expanding social and emotional wellbeing teams through Victoria and that these teams be supported by a new Aboriginal Social and Emotional Wellbeing Centre;
  • Establishing a residential mental health service facilitated through the Mental Health Implementation Office. This service will provide short-term treatment, care and support in a residential community setting, as an alternative to acute treatment in hospitals;
  • Expanding consumer and family-carer lived experience workforces and enhancing workplace supports for their practice;
  • Preparing a workforce reform and addressing workforce shortages by developing educational and training pathways;
  • Developing a new approach to mental health investment such as a levy or tax or a dedicated capital investment fund for the mental health system; and
  • Establishing a Mental Health Implementation Office to implement the Commission’s recommendations as set out in the Interim Report.

The Final Report

The Final Report builds on the key reforms tabled in the Interim Report. It explains system-wide changes that will create a mental health and wellbeing system that is contemporary and adaptable. The Final Report is made up of five volumes:

  1. Volume 1: A new approach to mental health and wellbeing in Victoria
  2. Volume 2: Collaboration to support good mental health and wellbeing
  3. Volume 3: Promoting inclusion and addressing inequities
  4. Volume 4: The fundamentals for enduring reform
  5. Volume 5: Transforming the system – innovation and implementation

Through these volumes, the Final Report makes 65 recommendations to improve Victoria’s mental health system. The Commission developed a path for reform using seven guiding principles upon which it based its recommendations. These were:

  1. The inherent dignity of people living with mental illness or psychological distress is respected, and necessary holistic support is provided to ensure their full and effective participation in society.
  2. Family members, carers and supports of people living with mental illness or psychological distress have their contributions recognised and supported.
  3. Comprehensive mental health treatment, care and support services are provided on an equitable basis to those who need them and as close as possible to people’s own communities – including in rural areas.
  4. Collaboration and communication occur between services within and beyond the mental health and wellbeing system and at all levels of government.
  5. Responsive, high-quality, mental health and wellbeing services attract a skilled and diverse workforce.
  6. People with lived experience of mental illness or psychological distress, family members, carers and supporters, as well as local communities, are central to the planning and delivery of mental health treatment, care and support services.
  7. Mental health and wellbeing services use continuing research, evaluation and innovation to respond to community needs now and into the future.

The Commission’s recommendations are centred on transformational reform. The major reform areas can broadly be grouped around four key features of the future mental health and wellbeing system.

A responsive and integrated system with community at its heart

The future mental health and wellbeing system will be restructured around a community based model of care. This means that people will be able to access treatment, care and support close to their homes and in their communities. Two parallel systems will be established. One system will be for infants, children and young people, and the other; adults and older adults.

A six tiered system has been developed, where the top level is aimed at the largest number of people and the lowest level – statewide services – the fewest. These levels will operate with a progressive level of specialisation. Broad reforms to New Adult and Older Adult Local Mental Health and Wellbeing Services are intended to create a “Broad Front Door” so more people can access such services than is currently the case.

A system attuned to promoting inclusion and addressing inequities

The new system would be designed to be particularly responsive to people and populations in Victoria with the greatest need. The Commission envisaged that this reform would require looking beyond the system to examine the social determinants of health, such as where people are born, grow, work live and age. This reform raises the possibility that stigma and discrimination will be diminished in the new mental health and wellbeing system, which in turn will create a sound foundation to support good mental health and wellbeing.

Re-established confidence through prioritisation and collaboration

The reforms will further encourage effective leadership, governance and oversight, accountability and collaboration across governments and communities, and ensuring that people with lived experience of mental illness or psychological distress are leading and partnering with others in reform efforts.

A new independent and statutory Mental Health and Wellbeing Commission will be established by the new reforms to hold the Victorian Government to account for the performance of the mental health and wellbeing system. A Chief Officer for Mental Health and Wellbeing will also lead a Mental Health and Wellbeing Division in the Department of Health. Importantly, the new Mental Health and Wellbeing Commission will include Commissioners with lived experience of mental illness or psychological distress and lived experience as a family member or carer. The Commission’s reimagined reforms will be enshrined in legislation in a new Mental Health and Wellbeing Act.

Contemporary and adaptable services

The Commission acknowledged that its reimagined mental health and wellbeing system would require a fundamentally different approach: the new system will need to adapt to changing expectations, trends and emerging challenges. Specifically, the new system will need to place a paramount importance on respecting consumers’ human rights every step of the way. This includes greatly reducing the use of seclusion and restraint and substantially reducing the use of compulsory treatment so that it is only used as a last resort.

Service providers will also be required to implement a minimum level of digital functionality to ensure continuity of care and navigation and to improve system access. Further, providers of mental health and wellbeing programs will need to agree to evaluation as part of funding arrangements. This will assist the system to continue to evolve and respond to the expectations of people engaged with the system.


Key recommendations of the Commission included:

  • Ensuring that people have access to services that are compassionate and responsive to their needs and are based on their rights and preferences;
  • Focussing on ensuring that treatment and care is available for all Victorians, no matter their background or need;
  • Redesigning services and moving from a crisis driven model to a community support and clinical services model that delivers better outcomes;
  • Setting up programs of support for families and carers that support them in their own right;
  • Foundational changes focused on creating new structures that support the sustainable mental health and wellbeing system;
  • Building a workforce that is diverse, large enough and with the right skills and experience;
  • Pioneering initiatives in Victoria that are led by Victorians who have lived experience; and
  • Looking beyond the traditional mental health system to create new ways to support mental health in the community and to make sure that people are well supported in the first place.

There is much more detail in the Report than can be included in a short summary such as this. The Victorian Government has committed to implementing all of the recommendations.

Russell Kennedy will continue to monitor the progress of the Government response and provide further information as it becomes available.


How we can help

If you require further information, please contact Michael Gorton, Solomon Miller, Jonathan Teh or Emma Turner.

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