Introduction

Occupational Therapy Australia

Occupational Therapy Australia (OTA) welcomes the opportunity to provide a submission to the Mental Health Select Committee’s Inquiry into the opportunities to improve mental health outcomes for Queenslanders.

OTA is the professional association and peak representative body for occupational therapists in Australia. As of December 2021, there were approximately 26,500 registered occupational therapists working across the government, private and community sectors in Australia. Queensland represents 20% of the Australian occupational therapy workforce (AHPRA, 2021). OTA is a member organisation of Mental Health Australia and Allied Health Professions Australia and is regularly represented by these entities. The association is strongly supportive of Mental Health Australia’s efforts to promote closer collaboration within the sector.

The role of occupational therapy in mental health

Occupational therapy is a client-centred health profession concerned with promoting health and well-being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life.

Occupational therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better support their occupational engagement (World Federation of Occupational Therapy (WFOT), 2019). Occupational therapists work with all age groups and in a wide range of physical and psychosocial areas. Places of employment may include hospitals, clinics, day and rehabilitation centres, home care programmes, special schools, industry and private enterprise (WFOT, 2019).

Mental health service provision is a longstanding and core area of practice in occupational therapy, dating back to the beginning of the profession more than 100 years ago. Occupational therapists work across the full spectrum of mental health, providing services to people with relatively common conditions, such as anxiety and mood disorders, as well as those which require more targeted interventions, such as psychosis, trauma-related disorders and complex presentations with multiple/chronic conditions involved. Occupational therapists have a specific and well-established role in child and adolescent mental health services, adult services, and aged care services (Hitch et al, 2018; Occupational Therapy Australia 2019).

Occupational therapists provide strengths-based, goal-directed services to improve mental health and wellbeing, and to help a person access personally relevant and valued roles and occupations. In this way, occupational therapists focus on the client’s function as well as their diagnosis. They recognise that two people with the same illness can have different levels of functioning; just as two people with the same level of functioning can have different health states. By understanding the person’s individual roles, circumstances and environments, occupational therapists support their clients to develop and attain goals relevant to their unique situation. A key strength of occupational therapists is their depth of understanding of the interplay between the bio psychosocial and cognitive issues that typically coexist with people with mental health conditions. This expertise is nationally recognised and well-established.

In Queensland, occupational therapists have a vital role in transforming the lives of people accessing mental health services, as well as through a range of services that address mental health and mental illness among the homeless, those in prison and justice services, those in mother and baby units, and with children in school settings. Functional outcomes for people with mental ill-health can include areas such as learning and application of knowledge, performance of everyday tasks, communication, mobility, self-care, care for others, interpersonal interactions and relationships – all of which are personally relevant or meaningful to the client.

Clients who are referred to an occupational therapist working in mental health are assisted to:

• Engage in activities that are personally relevant, such as specific vocational and leisure interests (D'Amico, Jaffe, & Gardner, 2018);
• Find meaningful work and undergo training to improve their career options, particularly where their ability to remain engaged for a sustained period has been affected as a result of their condition (D'Amico, Jaffe, & Gardner, 2018);
• Develop ways to enhance their social connectedness and community engagement (Gibson, D'Amico, Jaffe, & Arbesman, 2011);
• Develop skills and qualities such as assertiveness and self-awareness (Gibson et al., 2011); and,
• Develop or restore skills through focused strategies such as personalised behavioural/ functional goal setting, psychoeducation, graded exposure and skills-based approaches, experiential learning, group and individual work, and adaptive learning strategies (Burson, Barrows, Clark, Geraci & Mahaffey; 2010;- D'Amico, et al, 2018).

Training and Standards

Occupational therapists who work in mental health have extensive training and adhere to rigorous standards to ensure quality of care.

In Australia, all occupational therapy education programs are accredited to ensure they meet strict national standards. This is performed by the Occupational Therapy Council on behalf of the national regulator, the Australian Health Practitioner Regulation Agency (AHPRA). All Australian occupational therapy courses also meet international standards, as they are accredited by OTA on behalf of the World Federation of Occupational Therapists (WFOT).

In addition, as is common across all professions working in mental health which include additional training to be competent to do so, suitably trained occupational therapists also provide interventions such as psychotherapy, counselling, and other psychological strategies such as services for eating disorders, through the Better Access scheme (Department of Health (Australian Government Department of Health (DoH), 2017). There are approximately 1,000 OTA members currently endorsed to provide services under the Commonwealth Government’s Better Access initiative.

Response to consultation terms of reference

The following terms of reference are addressed in OTA’s response: (b) the current needs of and impact on the mental health service system in Queensland; (c) opportunities to improve economic and social participation of people with mental illness through comprehensive, coordinated, and integrated mental health services; and (h) mental health funding models in Australia.

Item (b) The current needs of and impact on the mental health service system in Queensland

A fragmented system

The mental health sector is facing unprecedented demand for services and there are many people with mental illness experiencing occupational deprivation and community disengagement (Gibson, D'Amico., Jaffe, & Arbesman, 2011; RACGP,2019). Only those consumers who are acutely unwell and have potential to harm themselves or others, or have high risk needs and complex presentations, meet the necessary criteria for tertiary mental health services. Care has become increasingly episodic due to high demand, and little attention is paid to the skills and supports that would maintain the person in the longer term (Vic Health, 2019d).

Care and support for consumers in transition from and to services is variable and inconsistent. A consumer may move from inpatient care back to community living with very little support. Community based services following discharge from inpatient units that provide shorter term care with outreach-based interventions is essential. Such models of care prevent a revolving door of deterioration and readmission. Once people do seek help, there may be complicated intake processes around eligibility, and delays before being seen, leading to frustration or lack of timely service provision.

Stressors such as homelessness, domestic violence, lack of employment opportunities, financial hardship, drugs and alcohol dependency, and limited support systems in our communities create a need for therapeutic supports, however the stigma of accessing these remains high.

It is evident that mental health, primary health, and community health systems require more investment and better integration to address growing demand for services. OTA invites the Committee to consider the extent to which this fragmented service delivery is attributable to the fact that different levels of government have responsibility for different areas of care, often without apparent reason. For example, Primary Health Networks (PHNs) which include among their stated objectives improving coordination of care to ensure patients receive the right care in the right place at the right time are a federal government initiative despite the obviously local nature of their purpose (Australian Government Department of Health (DoH), 2019). While OTA understands that Australia’s federated structure of governance must inevitably involve a role in healthcare for different levels of government, efforts should be redoubled to ensure greater coordination and continuation of care. It is imperative that those experiencing mental health challenges are not discouraged from seeking care or, worse, allowed to go unnoticed, because of fragmented service delivery.

There is an urgent need to invest in mental health services that directly address everyday occupational concerns

OTA believes there is an urgent need to invest in mental health services that directly address the everyday occupational concerns for people with mental health issues and their families (RCOT, 2018). These concerns are most frequently about the most important determinants of health and life expectancy, such as education, employment and social support (RCOT, 2018). Social determinants of health have a significant impact on mental health, so communities experiencing multigenerational difficulties, or with uncertain housing and high levels of unemployment, or farming communities adversely affected by weather, are at greater risk of poorer mental health. These problems are often compounded by limited protective and risk reducing opportunities for engagement and connection, limited access to learning new and different skills, and a lack of meaningful engagement opportunities. To address these challenges there needs to be a clear investment in the factors that are paramount to mental health and wellbeing such as housing, employment, social support, and meaningful occupation (WHO, 2001).

OTA strongly supports the broad adoption of the International Classification of Functioning (ICF) to ensure there is a shared (and destigmatised) language and approaches to mental health care. Such care should directly address the impact of mental health issues on activity and participation, place core emphasis on promoting mental health and wellbeing, and facilitate improved coordination and collaboration of care (WHO, 2001). We recommend that this include navigational pathways and support for mental health consumers and their families to ensure seamless support across services and throughout different stages of care, and, most particularly during transition of care from one stage to another (Manderson, McMurray, Piraino & Stolee, 2012).

It must be recognised that, to date, the implementation of the National Disability Insurance Scheme (NDIS) has failed those with mental illness. The NDIS as it stands currently operates on a deficit oriented framework whereby clients must constantly prove their disability. This is in direct conflict with the recovery oriented practice model whereby clients’ strengths are identified and built upon. The system is laborious and very difficult for consumers and carers to navigate. Access to the vocational and prevocational services provided by occupational therapists, often in conjunction with vocational consultants, has been all but lost (Furst et al, 2018).

Service models with fewer hurdles and less paperwork for participation in vocational opportunities (education, volunteer or paid positions), including the growth and expansion of the social firm movement, would be beneficial for consumers. Employment services should either be integrated with mental health services or be co-located with them.

The increasing demands for mental health service provision

The provision of high-quality health care in any sector or practice setting relies first and foremost on a skilled, well-supported health workforce. Occupational therapy is recognised as one of the five key professions in mental health care, making a significant contribution to the multidisciplinary team, increasingly recognised as the preferred model of care (Lloyd-Evans et al, 2018). Occupational therapy has an invaluable contribution to make to improve and sustain the mental health and wellbeing of Queenslanders across the full range of mental health services, however there is, at present, a shortage of available mental health occupational therapists.

OTA members report that mental health occupational therapists are experiencing overwhelming demand for services. Though more occupational therapists are graduating than ever before, the demand for services continues to outstrip supply. Many clients have been forced onto long wait lists and some occupational therapists have closed their books to new clients. According to members, there is a high demand for experienced occupational therapists who can support people with psychosocial disabilities and neurodevelopmental disorders involving suicidality, disassociation, anxiety, self-harm and other behaviours of concern.

OTA is concerned that workforce shortages are not limited to rural, regional, and remote Queensland. For example, OTA members advise that there is an insufficient number of mental health occupational therapists to meet the current needs of NDIS participants in Brisbane, Queensland. One member provides the following insights:

“I am a Brisbane mental health OT and I have closed my books to taking new clients as my waiting list became too long. I have a message on my voicemail and website stating this, but I still would receive about 5 messages a week asking if I can recommend someone else who can do mental health ot work that I do. Some clients have been on my waiting list and waited to see me for 36 weeks so far...there are also many people who did not find an alternative OT in that time and waited the full length of time to see me. I know many other mental health OTs who are not taking on new referrals. There seems to be great demand for experience OTs who can work within people with psychosocial disabilities and neurodevelopmental involving suicidality, self-harm, pain, dissociation, anxiety and behaviours of concern. I have taken my name off Find an OT and I know quite a few other mental health OTs who have done this in order to reduce the number of enquiries.”

It is worth noting that the Department of Health (2021) has identified occupational therapy as the fastest growing registered health profession in Australia. Between 2015 and 2019, the occupational therapy workforce experienced an annual growth rate of 7.0 per cent, compared with 3.7% for psychologists (Department of Health, 2021). In Queensland, the number of registered, practicing occupational therapists increased in Queensland by 49 per cent from September 2016 to 2021 (AHPRA, 2021). Despite new occupational therapy courses being established nearly every year, those graduating from university courses often do so with multiple job offers awaiting them. OTA members operating larger practices routinely report that they cannot fill job vacancies, despite the often very generous packages on offer. This creates a competitive environment for occupational therapists, many of whom are steered away from mental health service provision into other practice settings. While there is evidently an opportunity to improve mental health outcomes for Queenslanders through increased utilisation of the occupational therapy workforce, there is the challenge of ensuring that appropriate funding, support and high-quality supervision is in place to funnel those new graduate occupational therapists into mental health practice settings.

If access to mental health services is to be enhanced, it is vital that any increases in funding for such services include support and supervision for frontline mental health clinicians.

Item (c) Opportunities to improve economic and social participation of people with mental illness through comprehensive, coordinated, and integrated mental health services

Investment in the occupational therapy workforce

OTA believes individual mental health services require a strategic workforce plan that addresses recruitment, retention, and succession planning for the workforce. This, alongside the recommendations below, were highlighted in OTA’s submission to the Royal Commission on Mental Health in Victoria. It is worth noting that following the Royal Commission into Victoria’s Mental Health System, the Victorian Government announced an investment of $3.8 billion, or an $850 million increase per year, for their mental health services.

As outlined in OTA’s submission to the Royal Commission in Victoria:

• This strategy should include a career structure in mental health practice, education, research, management, and strategy (Vic Health, 2019e). Multi-disciplinary staff profiles that include occupational therapy across all professional tiers and grades in mental health services are also required to address the growing need for services and the growing complexity of need (ABS, 2014). Occupational Therapy Australia strongly believes this requires significant investment in occupational therapy services for the growing population a of people with mental health issues across the age spectrum (Vic Health, 2019d).

• Publicly funded clinical mental health services have historically been the most significant employer of occupational therapists working in mental health although growing numbers of occupational therapists are now working in non-government and community based mental health organisations. It is important to note that occupational therapists that work outside the mental health system also have a valuable role to play in supporting people with mental illness to manage life roles and activities. They also have a pivotal role in linking consumers into relevant mental health services and supports.

• Due to the complexity of need, Occupational Therapy Australia recommends that all acute inpatient units have occupational therapy as part of their core staffing profile. We would strongly recommend that realistic ratios of occupational therapists are determined for the acute setting in line with our nursing colleagues who have a well-established ratio of 1:8. As it currently stands, inpatient units employ a fraction of this number or, all too frequently, no occupational therapists at all.

• Community teams require an occupational therapy workforce that has a mix of equivalent full time funded positions to allow for both case management functions and discipline specific positions that enable occupational therapy specific assessment and intervention work. These core positions need to be included within the enterprise bargaining agreement, as the workforce is not numerous enough to advocate for itself within complex health and political systems.

• Area mental health services require occupational therapy educator positions to support the education and professional development of the workforce. To ensure parity with other professions such as nursing, this should be met with a ratio of 1 full time educator for every 5 occupational therapists. These positions enable occupational therapists to contribute to education and training of the broader workforce. For example, sensory modulation to ensure skills gained through intervention are carried over to gain the best outcomes for clients.

• The profession would welcome an investment in the development of leaders among those occupational therapists working in mental health services. OTA believes the establishment of strategic operational, educational and research positions for allied health professions would help achieve this. Significantly, in those mental health services where Chief Occupational Therapist positions are funded and well-integrated, the workforce has led innovative evidence-based practices and research. OTA strongly advocates for a greater commitment to the provision of leadership positions in occupational therapy, including the development of advanced practice roles (OTA, 2017). Positions that lead implementation of best evidence-based practice, specialist support, innovative quality improvement and research, and that will provide a career structure for occupational therapists, facilitate recruitment and retention of the workforce and, ultimately, facilitate optimal outcomes for people with mental illness.

An increase in the number of entry level/graduate positions for occupational therapists is required to ensure a workforce that develops the knowledge, skills and experience required to work effectively with people experiencing mental health issues. As highlighted in the Royal Commission into Victoria's Mental Health System, these graduate positions require specific allied health educator coordinator roles. These help ensure a strong career structure from graduate entry to advanced practice, leadership opportunities, and education and research positions for occupational therapists working in the mental health sector. This in turn will enhance workforce recruitment, retention, development, and the generation and use of best evidence-based practice, enabling optimal outcomes for consumers, families and communities within Queensland (Barriball et al, 2015).

Workforce initiatives should identify gaps in occupational therapy service delivery across the public and private health systems and should address the Queensland Productivity Commission’s findings in relation to the impact of growth in NDIS demand on the occupational therapy workforce. Any increases in funding for consumer access to mental health services must be met with appropriate resourcing to support growth and development of the mental health workforce. This includes a commitment to supporting workforce growth, including the availability of quality student placement opportunities and supervision to support early career opportunities.

A lead evidence-based statement on the purpose and scope of occupational therapy in mental health is currently being developed by OTA to ensure consumers and other health professionals are well informed about our integral role in this sphere. It will also highlight the fact that mental health approaches are well integrated in all occupational therapy services, regardless of their specialty (RCOT,2018).

Investment in housing, employment, and social support services

As stated above, there needs to be a clear investment in those factors that are paramount to mental health and wellbeing, such as housing, employment, social support, and meaningful occupation (WHO, 2001). This includes enhancement, integration and coordination of mental health rehabilitation support services that provide safe havens and therapeutic communities for consumers with complex, chronic and unremitting symptoms. There needs to be a focus on services that provide opportunities for social connection drop-ins, social skills, and therapeutic group programs to improve daily living skills. And there must be a greater commitment to safe housing with a focus on rehabilitation.

OTA strongly recommends the simplification and streamlining of NDIS processes to ensure that people with mental illness can navigate the system and access supports, services and therapeutic interventions when they want and need them. This will help them to participate in life tasks and roles in a meaningful way, enabling them to continue functioning in their community and preventing functional decline and hospital readmissions. The system should include navigational support for people with mental illness, and an increase in the availability and accessibility of Better Access and Medicare funded mental health supports that explicitly include evidence-based occupational therapy interventions. Such interventions directly address the confounding issues people with mental illness face when trying to engage in activity and participate in the community.

With regard to disability employment services, occupational therapists would welcome the greater involvement of vocational consultants in clinical mental health services across the state. Service models with fewer hurdles and less paperwork for participation in vocational opportunities (education, volunteer or paid positions), including the growth and expansion of the social firm movement, would be beneficial for consumers. Employment services should either be integrated with mental health services or be co-located with them.

Investment in community-based services

OTA strongly supports a greater emphasis on the broader contributors to mental health which enable an individual’s recovery within their community. As OTA (2020) noted in its supplementary submission to the Royal Commission into Victoria’s Mental Health System:

“While counselling is clearly an important stage in the process of recovery from mental illness, it is vital that the Royal Commissioners understand that recovery does not occur in a counsellor’s rooms. Rather, it occurs in a person’s environment, such as in the home, at school, in the supermarket or in the community. Recovery occurs when the person learns to function again – and occupational therapists are uniquely qualified to help achieve those personal goals.”

Estimates suggest that approximately 20 percent of patients consult their GP for what are primarily social problems (RACGP & CHF, 2020). These problems are not best addressed through a clinical or pharmaceutical response; rather, interventions should address the person’s physical and social environment.

As highlighted in the introduction of this submission, clients who are referred to an occupational therapist working in mental health are assisted to:

• Engage in activities that are personally relevant, such as specific vocational and leisure interests (D'Amico, Jaffe, & Gardner, 2018);
• Find meaningful work and undergo training to improve their career options, particularly where their ability to remain engaged for a sustained period has been affected as a result of their condition (D'Amico, Jaffe, & Gardner, 2018);
• Develop ways to enhance their social connectedness and community engagement (Gibson, D'Amico, Jaffe, & Arbesman, 2011);
• Develop skills and qualities such as assertiveness and self-awareness (Gibson et al., 2011); and,
• Develop or restore skills through focused strategies such as personalised behavioural/ functional goal setting, psychoeducation, graded exposure and skills-based approaches, experiential learning, group and individual work, and adaptive learning strategies (Burson, Barrows, Clark, Geraci & Mahaffey; 2010; D'Amico, et al, 2018).

Item (h) Mental Health Funding Models in Australia

Funding to support a multidisciplinary approach

OTA strongly supports multidisciplinary mental and physical health care, and recognises that each profession – clinical and non-clinical – brings a unique and valuable perspective to an individual’s recovery.

There is a pressing need for appropriate funding models to support mental health allied health professionals working across primary health services. The value of the multi-disciplinary team is particularly apparent in the care of those clients with whom primary health is most readily associated – those with mental health conditions and other conditions that often coexist such as chronic diseases and conditions, early developmental needs, or progressive health conditions. When such a model is not in place, it is ultimately the client who misses out – on choice, on person-centred care and, in the most severe or complex cases, on recovery and/or wellness.

Currently, the full scope and value of occupational therapy is underutilised and is too often inaccessible to clients in the primary health care setting. This results in an undue burden on other health services and a failure to utilise all available resources in an already understaffed field.

OTA members have noted that funding for primary health has become fragmented, and the system has become difficult for consumers to navigate, particularly in rural areas. Regrettably, from a primary healthcare perspective, several therapists have reported that it is simply not financially viable to work as a private practitioner in this space due to inequities within the system. There is currently a sizeable disparity between the Medicare Benefits Schedule rebates for services provided by psychologists and those provided by occupational therapists and social workers. For example, a clinical psychologist who sees a client between 30 and 50 minutes will receive a higher rebate than an occupational therapist who sees a client for 1 hour.

This lack of consistency can lead to significant out-of-pocket expenses for consumers. Moreover, lower rebates devalue the important work of occupational therapists and other professionals such as social workers, and make it harder for consumers to access their services. OTA is concerned that the lack of occupational therapy services in the primary care sector results in undue burden on clients, their families and carers, and the health care system as a whole.

While OTA acknowledges there must be a “gatekeeper” to assess the client and coordinate the work of the multi-disciplinary team, experience to date suggests that our already overstretched GPs struggle on occasion to perform this role. In addition, not enough GPs understand exactly what it is that some allied health professions do, and the nature of the contribution they make to a client’s wellbeing. This is particularly true of the role of occupational therapists in mental health service provision.

Moreover, there are indications of a looming GP workforce shortage. Any primary health care model that imposes an additional burden on GPs, in the face of a developing workforce shortage, is at best unreasonably optimistic, at worst irresponsible.

It is important that direct pathways to multidisciplinary care in the primary care setting are accessible, and that clients have the necessary support to navigate these pathways, in order to get the mental health care they need and want, in a timely manner and without unnecessary overreliance on GPs.

A coordinated system where GPs fully utilise the allied health workforce would help remove barriers for clients to access mental health services. Currently, by inefficiently funneling allied health through an already overstretched GP workforce, an unnecessary hurdle is added to accessing multidisciplinary care. In addition to referrals from GPs, access to mental health allied health professionals should be available and encouraged through other primary health programs.

Conclusion

OTA thanks the Mental Health Select Committee for the opportunity to respond to its inquiry into opportunities to improve mental health outcomes for Queenslanders. Please note that representatives of OTA would be pleased to appear before the Committee to expand on any of the matters raised in this submission.

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