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Special Edition - Royal Commission into Victoria's Mental Health System


Deinstitutionalised, underfunded, disconnected and overshadowed by stigma, the mental health system in Victoria has limped on for decades. What was so badly missing for so long were the voices of the people the system was supposed to serve.

On Tuesday of this week the Royal Commission into Victoria’s Mental Health System tabled its final report at a joint seating of Parliament. The report, all 3,500 pages, is huge even by the standards of other similar inquiries and is indicative of the Commissioners’ perspective on the size and scope of the problem.

From the outset, Premier Daniel Andrews committed to implementing all the Commission’s recommendations. In announcing the final report, Premier Andrews said:

"We're facing a watershed moment in Victoria's history. This report will change lives, and it'll save lives. The thousands of Victorians who have so bravely and so generously shared their personal stories deserve our full, undivided attention - and they deserve our help."

The Commissioners heard many voices indeed - 12,500 individuals and organisations made witness statements or contributed to various forums.

Storytelling in mental health is often traumatic. Healing comes not just with recognition, but also through genuine action. We are optimistic that this truly is a ‘watershed moment’ and that meaningful and sweeping reform will follow. As the Premier said, this is the time to get it done.

We offer deep respect and gratitude to people with a lived experience, including First Step clients and their family members, who contributed to the Royal Commission. It was crucial that your voices were heard because each one of you has uniquely relevant insights, and also because each one of you represents thousands of others who didn’t, or couldn’t, have that chance to speak.

We would also like to thank the Chair of the Royal Commission, Penny Armytage AM, along with Commissioners Professor Allan Fels AO, Dr Alex Cockram and Professor Bernadette McSherry for their sincerity, respect, compassion and generosity with their time, including visiting First Step to hear from our clinicians and clients.

In this special edition newsletter we will outline some of the key observations of the final report, share First Step’s featured case study, hear from Mary Pershall (author and advocate) and outline how we think, at this early stage, the recommendations may affect our crucial work.

Patrick Lawrence
Chief Executive Officer

Major themes identified by the Commission

It is important to acknowledge that the Commission’s work and report is extremely broad. The document itself offers many ways to view the information including summaries, info sheets, plain language recommendations, major reform areas, hundreds of infographics and much, much more. These are all accessible at However, most of us don’t have a spare month to read it, so we’ve packaged together some of what we think the crucial information is at this stage.

The Commission identified the following major themes - perhaps as you read them, reflect on whether they ‘line up’ with your own experience and understanding. All the themes are relevant to First Step’s work, but those in red are of greatest immediate relevance.

Demand has overtaken capacity
Community-based services are undersupplied
There is a ‘missing middle’ (‘not sick enough’ for more support)
Suicide is far-reaching
Access to services is not equitable (esp. Poverty)
The system is driven by crisis
The system has become imbalanced, with an over-reliance on medication.
Getting help is difficult
The system is antiquated
There is not enough focus on the promotion of good mental health and wellbeing
Trauma is unseen
The experience of poor mental health and wellbeing is different in rural and regional areas
Communities and places (e.g. work, school) do not adequately support good mental health and wellbeing
Limited focus on early years
Value of lived experience work is starting to be recognised, but faces challenges
Emergency departments are used as entry points
The system’s foundations need reform
Culturally safe services are not always available to Aboriginal communities
The workforce is under-resourced
Services are poorly integrated
Younger people are adversely affected
There is a substantial service gap for older people
The focus on personal recovery needs to be strengthened
Some groups face further barriers. (e.g. LGBTIQ+ people, refugees, CALD)
Mental illness can be compounded by housing instability
Stigma and discrimination are ever present
People in the criminal justice system do not get the support they need

Good mental health is not given priority
Dignity is often disregarded, and human rights breached

Four key features of the future mental health and wellbeing system

The Commission has a vision of a balanced system with more services delivered in community settings, extending beyond a health response to a more holistic approach to good mental health and wellbeing.

74 recommendations have been made and the Victorian Government has committed to implementing all of them. The major reform areas are grouped around four key features:

A responsive and integrated system with community at its heart where people access treatment, care and support close to their homes and their communities.

•   Rigid catchments, where people can only receive specialist services based on where they live, will be dismantled.
•   Services will be delivered based on a philosophy of ‘how can we help?’ to enable people to be supported from their first to their last contact.
•   Tertiary-level (hospital) high-intensity and complex support responses will utilize multidisciplinary teams, responding to crisis calls 24/7 and offering an alternative to police and ambulance callouts and visits to emergency departments.
•   Multidisciplinary care for bed-based services will be delivered in a range of settings, including a person’s home and fit-for-purpose community and hospital environments.
•   The role of families, carers and supports will be recognised as central with the establishment of family- and carer-led centers.
•   A statewide trauma centre will deliver best possible mental health outcomes for people who have experienced trauma.
•   A statewide service for people living with mental illness and substance use or addiction will be established to provide integrated treatment, care and support.

A system attuned to promoting inclusion and addressing inequities so that all Victorians may enjoy optimal mental health and wellbeing.

•   Investment in the leadership, coordination and delivery of a statewide approach to prevention and promotion activities.
•   Partnerships with Victoria’s diverse communities to set new expectations of services.
•   ‘Community collectives’ will bring together community leaders and members to promote social connection and inclusion.
•   More mental health workers in rural and regional communities.
•   Anti-stigma programs developed, implemented and evaluated.
•   Improved access to legal protection from mental health discrimination.

Re-established confidence through prioritisation and collaboration across governments and communities and ensuring people with lived experience are leading reform efforts.

•   An independent and statutory Mental Health and Wellbeing Commission which will include Commissioners with lived experience and a Mental Health and Wellbeing Division within the Department of Health.
•   Services will be commissioned in new ways to respond to the preferences and expectation of people living with mental illness, families, carers and supporters.
•   A new Suicide Prevention and Response Office.
•   The Commission’s reimagined mental health and wellbeing system will be enshrined in a new legislation – a new Mental Health and Wellbeing Act.

Contemporary and adaptable services that respond to changing expectations, trends and emerging challenges

•   Workforce reforms to build a workforce that is diverse, large enough and with the right skills and experience.
•   Changes and shifts to practices and cultures, ensuring consumers human rights are upheld.
•   A new approach to information management to help collect, use and share information effectively, safely and efficiently.
•   Innovation in treatment, care and support through a dedicated mental health and wellbeing innovation fund, with a strong focus on translational research.
•   All new programs will need to agree to evaluation as part of funding arrangements.

This is a comprehensive program of reform with new, well-funded governance bodies to ensure that the reform is enacted and that the results are satisfactory. If we do this, Victoria will be a world leader, and our most vulnerable Victorians will reap the benefits.

To learn more and read the Final Report visit

First Step featured in the Final Report

First Step contributed in many ways to the Royal Commission over the journey:

-   Commissioners Penny Armytage and Dr Alex Cockram attended a 2.5 hour Zoom ‘visit’ to First Step where they heard from senior staff, a First Step client and the family member of a client.
-   Several First Step clients took place in a face-to-face lived-experience forum
-   Senior managers of First Step (Joe Fishburn – Mental Health Services, and Tania Wolff – First Step Legal, Patrick Lawrence - CEO) took part in forums on community services, health justice partnerships and trauma-informed care.
-   CEO Patrick Lawrence and First Step Legal each submitted comprehensive Witness Statements to the Royal Commission

It was crucial that First Step’s unique perspective was heard by the Commissioners and it is important that our insights appear in many sections throughout the final report, particularly in Volume 2 (Collaboration to support good mental health and wellbeing) and Volume 3 (Promoting inclusion and addressing inequalities). Our clients are quoted several times throughout the document, as are our expert opinions on trauma, stigma,

Of greatest significance is the chapter 22(volume 3) Integrated approach to treatment, care and support for people living with mental illness and substance use or addiction. This chapter outline three models of care, one or more of which must be adhered to by any organisation seeking funding. The first of these models, the most integrated example, is ‘multi-disciplinary teams.’ And First Step is the one example given:

“An example of care provided by multidisciplinary teams is that delivered by First Step (mentioned throughout this chapter). First Step’s model of care involves multidisciplinary practitioners and clinicians working together to deliver care in a single setting. The team includes GPs, an addiction specialist physician, nurses (including mental health nurses), lawyers, clinical and counselling psychologists and a psychiatrist.”

The document also quotes the World Health Organization stating that ‘[t]ruly integrated care involves more than co‑locating health workers with diverse specialties into the same building.’ First Step has a decade of experience in this area, and we can clearly explain to the new regional commissioning bodies and Mental Health Reform Victoria, just exactly what is involved in developing that ecosystem of whole-person care. It is crucial that First Step’s unique voice continues to be heard on these issues, and this report will greatly aid in our advocacy for the most vulnerable people in the community.

Mary Pershall’s interview with First Step

Mary Pershall provided a witness statement and gave evidence to the Commission, describing her experiences as the mother of a daughter, Anna, who used crisis services frequently before being jailed for killing her housemate.

Mary told the Commission that the mental health system failed to recognise the severity and escalation of Anna’s mental illness and distress because they treated each crisis event in isolation and failed to engage with people who could have told them about Anna’s history.

In her witness statement, Mary asks:

“Why couldn’t the authorities have taken a team approach and consulted people who actually knew this young woman? They could have talked to Dr D who had spent hundreds of hours with Anna. They could have consulted John and Katie and me, who had loved and cared for her for 26 years.”

In a series of short interviews with First Step, Mary shares her reflections on a broken system and provides insight into how a future mental health and wellbeing system can support Anna, once she is released from prison.

Here is the first interview:



Make sure you follow us on Facebook, so you don’t miss hearing Mary’s story over the coming weeks.