actcoss text final.indd - ACT Council of Social Service

no wrong doors 

Towards an integrated mental health service system in the ACT 

June 2007 

1

about actcoss 

ACTCOSS acknowledges that Canberra has been 

built on the traditional lands of the Ngunnawal 

people. We pay our respects to their elders and 

recognise the displacement and disadvantage 

traditional owners have suffered since European 

settlement. ACTCOSS celebrates the Ngunnawal’s 

living culture and valuable contribution to the ACT 

community. 

The ACT Council of Social Service Inc. (ACTCOSS) 

is the peak representative body for not-for-profit 

community organisations, people living with 

disadvantage and low-income citizens of the 

Territory. ACTCOSS is a member of the nationwide 

COSS network, made up of each of the state 

and territory Councils and the national body, the 

Australian Council of Social Service (ACOSS). 

ACTCOSS’ objectives are representation of people 

living with disadvantage, the promotion of equitable 

social policy, and the development of a professional, 

cohesive and effective community sector. 

The membership of the Council includes the majority 

of community based service providers in the social 

welfare area, a range of community associations 

and networks, self-help and consumer groups and 

interested individuals. 

CONTACT DETAILS 

Phone: 02 6202-7200 

Fax: 02 6281 4192 

Mail: PO Box 849, Mawson 2607 

E-mail: actcoss@actcoss.org.au 

WWW: http://www.actcoss.org.au 

Location: Shop 9, Level 1, 

67 Townshend St , Phillip ACT 2606 

Director: Ara Cresswell 

Policy Officer: Jacqueline Phillips 

June 2007 

© Copyright ACT Council of Social Service 

Incorporated 

This publication is copyright, apart from use by 

those agencies for which it has been produced. 

Non-profit associations and groups have permission 

to reproduce parts of this publication as long as 

the original meaning is retained and proper credit 

is given to the ACT Council of Social Service Inc 

(ACTCOSS). All other individuals and Agencies 

seeking to reproduce material from this publication 

should obtain the permission of the Director of 

ACTCOSS. 

ACTCOSS receives funding from the Community 

Services Program (CSP) which is funded by the ACT 

Government. 

ACTCOSS advises that this document may be publicly 

distributed, including by placing a copy on our 

website. 

NO WRONG DOORS Towards an integrated mental health service system in the ACT•June 2007 

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Table of contents 

ABOUT ACTCOSS............................................2 

TABLE OF CONTENTS......................................3 

ABBREVIATIONS............................................. 4 

EXECUTIVE SUMMARY................................... 5 

PART 1: 

Introduction...................................................9 

Background and methodology............................9 

The community mental health sector in context: 

towards an integrated service system..................9 

Core policy principles........................................11 

Exploring the concept of collaboration..............13 

PART 2: 

The relationship between 

the ACT community sector and 

the ACT government...................................16 

The 2003-2008 ACT Mental Health Strategy 

and Action Plan................................................16 

The ACT Social Compact..................................17 

An analysis of current relationships 

between the ACT government and the 

community sector.............................................18 

PART 3: 

The relationship between the community 

mental health sector and other parts of 

the community social service system........24 

Alcohol and drug services................................. 26 

Housing providers and 

accommodation services...................................29 

Employment services........................................30 

Primary health care...........................................30 

Youth services.................................................. 31 

Indigenous social services.................................32 

Community legal centres and Legal Aid............32 

Disability services..............................................33 

Recommendations: Improving the relationship 

between the community mental health sector 

and other parts of the community social service 

sector...............................................................34 

CONCLUSION................................................ 40 

REFERENCES................................................. 41 

APPENDIX A..................................................42 

APPENDIX B..................................................43 

The funding relationship between the 

ACT Government and community 

sector organisations....................................18 

The service delivery relationship between 

community and government services: 

formal and informal....................................19 

Recommendations: Improving the funding, 

formal inter-agency and referral relationships 

between the community sector and the 

ACT government..............................................22 

3 

Towards an integrated mental health service system in the ACT•June 2007 NO WRONG DOORS

abbreviations 

ACOSS: 

Australian Council of Social Service 

MHACT: 

Mental Health ACT 

ADACAS: ACT Disability, Aged and Carer 

Advocacy Service 

ACTCOSS: ACT Council of Social Service 

ADHD: Attention-Deficit Hyperactivity Disorder 

ADP: Alcohol and Drug Program 

AOD: Alcohol and Other Drug 

MHCC: 

MHCN: 

MOU: 

NGO: 

PPEI: 

Mental Health Community Coalition 

Mental Health Consumer Network 

Memorandum of Understanding 

Non-Government Organisation 

Promotion, Prevention 

and Early Intervention 

CALD: 

CATT: 

CLC: 

COAG: 

GP’s: 

Culturally and Linguistically Diverse 

Crisis Assessment and Treatment Team 

Community Legal Centre 

Council of Australian Governments 

General practitioners 

SAAP: 

UN: 

WHO: 

WRLC: 

Supported Accommodation and 

Assistance Program 

United Nations 

World Health Organisation 

Welfare Rights and Legal Centre 

HACC: 

Home and Community Care 


4

executive summary 

The purpose of this paper is to explore the extent to 

which the community mental health system in the 

ACT is linked and integrated into a broader social 

service system. In doing so, this paper examines 

the relationship between community mental health 

services in the ACT, government agencies and the 

broader community social service system. The paper’s 

starting premise is that mental illness is a social 

issue that transcends sectoral boundaries. Research 

demonstrates that mental health consumers are more 

likely to be affected by a number of other issues, for 

example, alcohol and drug problems, homelessness, 

poverty and unemployment. As a result, mental 

health consumers commonly need to access a broad 

range of social services, including alcohol and drug 

services, crisis accommodation services, employment 

or vocational rehabilitation services, primary health 

care services and community legal services. The 

coordination of these services is critical to ensure that 

consumers receive appropriate and timely assistance, 

are referred on to relevant services and are not left to 

fall through service or sectoral ‘gaps’. 

Part One of this paper outlines the background and 

research methodology of this project. The need for 

an integrated service system is established and the 

governmental policy shift towards inter-sectoral 

linkage is highlighted. The core policy principles 

which inform the paper are then defined, concluding 

with a definition and discussion of ‘collaboration’, 

a central concept throughout the paper. 

In Part Two, the relationship between the ACT 

community sector and the ACT Government is 

explored. This analysis is situated within the context 

of the ACT Mental Health Strategy and Action Plan 

2003-2008 and the ACT Social Compact. Three key 

aspects of the relationship are examined: the funding 

relationship, formal inter-agency agreements (e.g. 

memoranda of understanding or ‘MOUs’) and less 

formal service delivery practices of informationsharing, 

referral and client case management. 

A number of recommendations are proposed, 

designed to improve the relationship between the 

community sector and government around mental 

health service delivery. 

Finally, in Part Three, the relationship between the 

community mental health sector in the ACT and 

other parts of the community social service system is 

considered. The relationship between the community 

mental health sector and specific sub-sectors is 

considered individually. Sub-sectors discussed include: 

• Alcohol and drug services; 

• Housing providers and accommodation services; 

• Employment services; 

• Primary health care services; 

• Youth services; 

• Indigenous social services; 

• Community legal centres and Legal Aid; and 

• Disability services. 

A series of recommendations are proposed, designed 

to improve intersectoral relationships and service 

system integration. 

It is hoped that by closely analysing the state of 

relationships between community mental health 

services and other parts of the social service system 

(government and community) priority issues can 

be identified and addressed. In particular, it is 

hoped that the recommendations proposed in this 

report provide a framework for action to support 

community organisations to coordinate, cooperate 

and collaborate. 

SUMMARY OF KEY FINDINGS 


sector and government 

1. The ACT Government has made a policy 

commitment to develop further links and 

partnerships with the community mental health 

sector and to enhance coordination between 

inpatient and community based mental 

health service services. 

5 Towards an integrated mental health service system in the ACT•June 2007 NO WRONG DOORS

2. A lack of awareness by government and 

community sector staff in relation to the 

existence and content of the Social Compact is 

impeding its effectiveness as a framework for 

relations of recognition and partnership. 

3. Little research or evaluation of MOUs between 

government departments and community 

organisations has been conducted, such that 

it is difficult to gauge their effectiveness or 

highlight areas for improvement. The major 

impediment to their effectiveness identified by 

participants was ignorance of the existence and 

terms of agreements by government staff. 

4. The need for improved system level integration 

between government departments and 

sub-sectors was identified, as well as the 

need for a clear statement on the interaction 

between Mental Health ACT (MHACT) and the 

rest of the sector. 

5. Consultation participants perceived that interdepartmental 

‘siloing’ was still a significant issue 

despite government commitments to improve 

inter-departmental cooperation. 

6. There is a general perception that community 

mental health services are under-funded and 

overlooked in the allocation of mental 

health funding. 

7. Accountability reporting was consistently 

identified as a challenge by community 

organisations from across the sector, particularly 

affecting small organisations. 

8. Service delivery relationships between 

community organisations and Mental 

Health ACT were variable, with a need for 

improved referral relationships and joint case 

management, particularly for dual-diagnosis 

service-users. 

9. Philosophical, language and diagnosis 

differences were said to pose challenges 

to cooperation between government and 

community services and to generate service 

delivery gaps. 


mental health sector and other parts of the 

social service system 

1. Few community mental health organisations 

have entered formal agreements with other 

community organisations or been involved in 

joint projects. 

2. There is currently a low level of mental health 

community case management. 

3. Many referral relationships currently depend 

on individual contacts rather than entrenched 

service relationships. Many of these relationships 

are perceived as ‘chaotic’ by consumers. 

4. Relationships between the mental health and 

alcohol and drug (AOD) sectors remain variable, 

with dual-diagnosis service users in some cases 

unable to get simultaneous support for 

co-occurring disorders. 

5. Cross-sectoral training was identified as a 

priority training area, particularly around 

dual-diagnosis. 

6. Linkages between employment services and 

other services are mostly ad hoc 

rather than 

systemic or formal inter-agency relationships. 

7. There is a need to increase awareness about 

community mental health services within 

primary health care services to improve referral 

relationships. 

8. The need to improve linkages between youth 

services and mental health networks and to 

include youth services in mental health policy 

consultations was identified. 


6

9. Youth aged between 18 and 25 years of age 

were identified as an area of unmet need. This 

requires a coordinated response to ensure that 

this population group receives treatment and 

support in an age-appropriate setting. 

10. There is a need for improved and coordinated 

services for Indigenous and CALD mental health 

consumers due to the lack of coordination 

between specific and mainstream services. 

Efforts should be made to make mainstream 

services more accessible for Indigenous and 

CALD potential service-users. 

11. A conceptual and service segregation persists 

between disability and mental health which 

undermines advocacy as well as services for 

dual-disability clients. 

12. Participants highlighted the need for more faceto-face 

contact between workers and managers 

from different community organisations to 

establish networks and referral links. There is 

currently no forum for cross-sectoral planning 

and networking around mental health service 

issues. 

13. The resource, time and logistical challenges of 

collaboration were identified, and the need 

for government support and incentives to 

collaborate was emphasised. 

14. There is a need for clearer protocols around 

entry, discharge and transfers between services. 

15. A review of organisational structures is a 

necessary pre-requisite to collaboration. 

16. Lack of awareness about community mental 

health services was cited as a problem for 

potential service-users, community sector 

workers, clinical workers and government 

service staff. 

SUMMARY OF RECOMMENDATIONS 

Recommendations to improve the 

relationship between the community 


1. Develop inter-departmental service agreements 

to facilitate a whole-of-government approach to 

mental health. 1 

2. Conduct periodic training in the terms and 

implications of the Social Compact and the 

Community Sector Funding Policy for all new 

staff in the government sector, and regular 

information and review forums for community 

sector workers. 

3. Ensure meaningful community participation in 

any review of the distribution of resources in 

the sector and ensure that distribution criteria 

remain flexible. 

4. Review the impact of MOUs between 

government departments and community sector 

agencies, to improve their effectiveness. 

5. Commit to the development of sectoral MOUs 

and consider the adoption of a ‘Primary Care 

Partnerships’ model of coordinated service 

delivery. 

Recommendations to improve the 

relationship between the community 

mental health sector and others parts of 

the community social service system 

6. Engage in the mapping of community sector 

service delivery to those affected by mental 

illness, identifying service gaps and needs. 2 

7. Fund and facilitate a permanent ACT crosssectoral 

mental health planning network, 

involving community sector service managers, 

front-line workers and consumers. 

___________________________________________________________________________________________________________________________ 

1 

2 

This recommendation is consistent with Recommendation 1(d) of the Mental Health Council of Australia, Not for Service: Experiences of 

injustice and despair in mental health care in Australia (2005) at 17 

This reflects recommendation 6 of The Australian Psychiatric Disability Coalition Inc and The Head Injury Council of Australia Inc, Trying Desperately: The Role 

of Non-Government Organisations in an Integrated System of Care for People with Psychiatric Disability or Acquired Brain Injury, Tony Wade and Associates P/L, 

Brisbane, May 1995 at 9. This was also recommended by the Human Rights and Equal Opportunity Commission, Report of the National Inquiry into the Human 

Rights of People with a Mental Illness, (1993) (‘Burdekin Report’). This paper is intended to be a contribution to the mapping process, but more detailed research 

needs to be undertaken. 


8. Encourage and support the development 

of collaborations and partnerships between 

community sector service providers and with 

government, observing the principles embodied 

in the Social Compact. 

9. Fund organisations to engage in case 

management and service coordination. 

10. Develop clearer protocols around entry, 

discharge and transfers, between and within 

the government and community service 

systems 3 . 

11. Community organisations review internal 

structures to ensure that they are supportive of 

collaboration. 

13. Support the community mental health sector 

to adequately train workers, including crosssectoral 

training and staff exchanges. 

14. Investigate options to improve consumer 

information services, for example, establishing 

a central information and referral shopfront 

and/or a central telephone information line able 

to provide information about government and 

community mental health services. 

15. Develop specific mental health policies targeting 

vulnerable population groups, including youth 

aged 18-25 years and members of Indigenous 

and CALD communities. 

12. Develop and facilitate an integrated dualdiagnosis 

strategy. 

___________________________________________________________________________________________________________________________ 

3 

This reflects recommendations made by the Mental Health Coordinating Council, Building Effective Non Government Mental Health Services in NSW, 

15 November 2005 at 3. 


8

part 1: introduction 

BACKGROUND AND METHODOLOGY 

This paper was developed following discussions with 

the Mental Health Community Coalition (MHCC) 

on strengthening the community mental health 

sector and improving outcomes for those affected 

by mental illness. It was agreed that separate papers, 

each with a different focus, would be the most 

effective and appropriate way of exploring key 

issues. As a result, the MHCC has developed a paper 

with a ‘sector development’ or intra-sectoral focus, 

examining organisational and sectoral challenges 

and service delivery model options within the 

community mental health sector. The ACT Council 

of Social Service (ACTCOSS) separately embarked 

on a paper with a focus on the community mental 

health sector in context. This has developed into an 

analysis of current relationships between different 

parts of the Australian Capital Territory (ACT) 

social service system, community and government, 

examining referral links, coordination, cooperation 

and collaboration. 

This paper begins by outlining the core policy 

principles which inform ACTCOSS’ analysis of 

mental health service delivery systems and policies. 

It explores the concept of collaboration, its various 

forms, and ways in which governments can facilitate 

inter-agency collaboration. The relationship between 

community mental health services and government is 

then considered. Funding, referral and inter-agency 

relationships with government departments and 

services are analysed. In Part Three, relationships 

between the community mental health sector and 

other parts of the community service sector (for 

example, housing, alcohol and drug and Indigenous 

services) are explored. In each part of the paper, 

recommendations are proposed to respond to 

identified challenges under each heading. 

This policy paper is informed by an extensive survey 

of relevant academic literature in addition to a 

review of international, national, state and territory 

policy documents and consideration of stakeholder 

consultative input. Two consultative forums, jointly 

facilitated with the MHCC, were held with mental 

health community service providers, the first in 

November 2006 and the second in February 2007. 

ACTCOSS also facilitated a consumer forum, hosted 

by the Mental Health Consumer Network (MHCN), 

on 27 February, 2007. In addition, we conducted 

individual consultations with some 13 community 

sector organisations from across the service sector. 

These organisations are all involved in providing 

services to mental health consumers, though do not 

all provide mental health specific services. A list of 

these services is provided at Appendix A. During the 

consultations, participants were asked a series of 

generic questions, included in Appendix B. It should 

be noted that consultations engaged with a limited 

number of organisations from across the service 

system. As a result, consultation feedback should not 

be taken to represent uniform or agreed positions 

across the sector, but rather, trends emerging from 

the sample of organisations consulted. Similarly, 

examples provided of partnerships and collaboration 

should not be understood to exclude other examples 

not highlighted during the consultation process. 

THE COMMUNITY MENTAL HEALTH SECTOR 

IN CONTEXT: TOWARDS AN INTEGRATED 

SERVICE SYSTEM 

ACTCOSS has long argued that the best outcomes 

for service-users can only be secured through an 

integrated service system, characterised by mutual 

respect, effective referral and information pathways 

and a commitment to coordination, cooperation, 

and collaboration. In this paper, we have used the 

expression ‘no wrong doors’ to describe an approach 

to service delivery in which each organisation in the 

service system is supported to assist all those who 

seek help, either by providing services directly or 

referring the individual on to another organisation 

able to assist. This paper is premised on an awareness 

of the social determinants of health and reflects an 

understanding that both the causes and effects of 

mental illness cross sectoral boundaries. Any reform 

of mental health services in the ACT must therefore 

take a systemic and cross-sectoral approach to 

be most effective. The community mental health 

sector must be seen as part of a broader network 

of community sector services, and a necessary 


complement to government services. Consistent with 

this view, the ACT Mental Health Strategy and Action 

Plan 2003-8 recognises the need for a systemic 

approach, expressing a commitment to ‘refining 

service delivery systems to improve outcomes’. 4 

This Part analyses the extent to which a systemic 

approach has been developed, highlights existing 

examples of cooperation and explores possible 

strategies to improve system integration. 

Mental health interventions are positioned 

on a continuum from ‘prevention’ through to 

‘maintenance and support’. 5 Community mental 

health services play an important role in early 

intervention, prevention and promotion, as well as 

recovery from a mental health episode. Feedback 

from service provider and consumer consultations 

indicated that individuals in regular contact with 

community services were less likely to experience 

an acute mental health episode, with warning signs 

likely to be detected by community workers and 

necessary support provided or acquired through 

referral. 6 At the prevention end of the spectrum, 

while mental health services play an important role, 

broader social support structures are also critical. 

These include families, schools, employment, primary 

health care services, drug and alcohol services, 

housing and accommodation services and other 

social service providers. 7 The roles of clinical mental 

health services, community mental health services 

and this broader range of social services are interdependent 

and complementary. The coordination 

and integration of these services is critical to ensure 

that service-users do not fall through structural 

gaps but receive timely, appropriate and effective 

treatment and support. 

The importance of inter-sectoral collaboration around 

mental health service delivery has been recognised 

at an international, national and territory policy level. 

This is consistent with a general social service policy 

trend towards integrated service systems and the 

trans-sectoral implications of mental health. Indeed, 

the World Health Organisation (WHO) has recognised 

that, ‘(t)he needs of people with mental disorders 

transcend traditional sectoral boundaries’. 8 Following 

this, the World Health Report recommended 

inter-sectoral linkage as a way to improve health 

service delivery. The WHO has also developed some 

general principles for mental health inter-sectoral 


At the national level, the Council of Australian 

Governments (COAG) National Action Plan on 

Mental Health 2006-11 emphasises coordination 

and collaboration between government, private 

and community providers. In addition, the National 

Mental Health Policy and Strategy, the National 

Homelessness Strategy, and the National Drug 

Strategy all express a commitment to inter-sectoral 

collaboration and partnership. 9 The evaluation 

of the Second National Mental Health Plan found 

that continuity of care remained elusive, while 

inter-sectoral collaboration needed to be pursued 

10 

systematically, rather than in an ad hoc 

fashion. 

Pilot ‘linkages’ programs around Australia have 

shown consistently positive results, with patient care 

improving and provider collaboration continuing 

post-trial. 11 In addition, community sector mental 

health policy papers have stressed the importance of 

such collaboration. This has been a constant theme 

in a series of Mental Health Council of Australia 

reports, which call for community coordination 

and whole-of-government approaches. 12 The Time 

for Service Report identified ‘collaborative primary 

___________________________________________________________________________________________________________________________ 

4 

At 41. 

5 

Australian Council of Social Service, Submission to Senate Select Committee on Mental Health, ACOSS Info 376 – July 2005, at 14. 

6 

This is despite the fact that ‘indicated prevention’ is often conceived as a clinical rather than community rehabilitation and support function. 

7 

Australian Council of Social Service, Submission to Senate Select Committee on Mental Health, ACOSS Info 376 – July 2005, at 14 

8 

World Health Organisation, The Mental Health Context (Mental Health Policy and Service Guidance Package), 2003 at 29. 

9 

For example, The National Mental Policy states that it ‘aims to encourage co-operation between mental health services and the various programs and services 

needed to enable people with severe mental health problems and mental disorders to participate more fully in community life. 

10 As described in the ACT Mental Health Strategy and Action Plan 2003-8 at 34. 

11 Gavin Andrews, ‘The crisis in mental health: the chariot needs one horseman’, (2005) 182(8) MJA 372. 

12 See, for example, The Mental Health Council of Australia, Not for Service: Experiences of injustice and despair in mental health care in Australia (2005) at vii-viii. 


10

care’ initiatives as a key funding priority. 13 A recent 

Vicserv report stressed the importance of effective 

community linkages with alcohol and other drug 

(AOD), community health, employment, education, 

housing and homelessness services. 14 

The ACT Mental Health Strategy and Action 

Plan 2003-8 also expresses a commitment to 

the development of an integrated service system 

to improve continuity of care. It recognises the 

consumer and community perception that service 

gaps exist, particularly between inpatient and 

community services and discharge planning. 15 

In response, it commits the ACT Government to 

developing ‘whole-of-government’ responses to 

mental health issues, and to working with the 

community sector to coordinate service delivery. 

The Plan recognises that individuals with high and 

complex needs are likely to access a large variety of 

services. 16 In order for the service system to respond 

early to manage these needs, or prevent a crisis 

episode, it requires a high degree of communication 

and cooperation. Further, the ACT Action Plan for 

Mental Health Promotion, Prevention and Early 

Intervention 2006-2008 emphasises the importance 

of strengthening existing networks as part of an 

effective promotion strategy. As such, it calls on 

‘existing and new community networks’ to play a role 

in mental illness promotion and illness prevention 

by, for example, developing closer collaborations, 

exchanging information and supporting innovation. 

The Action Plan also states that the pattern of 

‘working in isolation and within single sectors’ acts 

as an ‘inhibiting factor’ to an effective and integrated 

Promotion, Prevention and Early Intervention (PPEI) 

service system. 17 However, it does not provide 

practical detail as to how the ACT Government 

intends to support network strengthening and 

enhance the capacity of the community sector to 

collaborate and innovate. 

CORE POLICY PRINCIPLES 

This project is informed by a number of core 

principles. These relate to the nature of mental 

illness, the relationship between mental health 

and other social issues and best approaches to 

mental health service delivery and policy. These core 

principles include: 

• An understanding of the social determinants 

of health; 

• A population health approach; 

• A commitment to equitable access to 

health care; 

• A commitment to the human right to health; 

• A belief in community responsibility for mental 

health; and 

• A belief in the value of coordination, 

partnership and collaboration. 

An understanding of the social 

determinants of health 

Mental health is determined by the interaction of 

numerous social, biological, psychological, economic 

and environmental factors. Poverty is one of the 

strongest indicators of mental disorders. 18 This paper 

reflects the belief that the causal relationships that 

exist between mental health and poverty, abuse 

and disadvantage are complex and dynamic. This 

social determinants of health approach is consistent 

with current ACT Government health and mental 

health policy. The ACT Action Plan for Mental Health 

Promotion, Prevention and Early Intervention 2006- 

2008 (‘the Action Plan’), reflecting the Canberra 

Social Plan and the ACT Health Action Plan 2002, has 

a ‘focus on the social factors that determine health 

and wellbeing.’ 19 

___________________________________________________________________________________________________________________________ 

13 Mental Health Council of Australia, Time for Service: Solving Australia’s Mental Health Crisis, June, 2006 at 5. 

14 Vicserv, The development of Psychiatric Disability Rehabilitation and Support Services in Victoria (2003), Part 9. 

15 At 27. 

16 At 47. 

17 At 7. 

18 World Health Organisation, The Mental Health Context (Mental Health Policy and Service Guidance Package), (2003) at 5 and 27. 

19 Foreword to The ACT Action Plan for Mental Health Promotion, Prevention and Early Intervention 2006-2008 at iii. 

11 


A population health approach 

This paper’s emphasis on population health is 

consistent with the most recent National Mental 

Health Plan 2003-8 and the ACT Mental Health 

Strategy and Action Plan 2003-2008. The latter 

defines the vision for mental health in the ACT 

as follows: 

..to utilise a population health framework to 

develop an environment which supports and 

enhances the capacity of people in the ACT to 

achieve and maintain good mental health. 20 

The Strategy defines a population health approach 

as one in which ‘consideration is given to the mental 

health needs of the whole population, from mental 

health promotion through to long term care and 

recovery, with attention paid to the specific needs of 

groups within the population.’ 21 Further, it: 

… takes into account the complex influences on 

mental health, encourages a holistic approach 

to improving mental health and wellbeing and 

develops evidence based interventions that meet 

the identified needs of population groups. 22 

A commitment to equitable access 

to health care 

ACTCOSS is committed to the principle of equal 

access to quality health care, regardless of income, 

socio-economic status, physical ability or disability and 

geographic location. Indeed, access to primary health 

care is a determinant of positive health outcomes. 

This approach is consistent with the ACT Mental 

Health Strategy and Action Plan 2003-2008, which 

includes as one of its four broad principles, ‘timely, 

equitable access to appropriate services of an 

assured quality’. 

A commitment to the human 

right to health 

This is expressed in article 25(1) of the Universal 

Declaration on Human Rights as follows: 

Everyone has the right to a standard of living 

adequate for the health and well-being of himself 

and of his family, including food, clothing, 

housing and medical care and necessary social 

services, and the right to security in the event of 

unemployment, sickness, disability, widowhood, 

old age or other lack of livelihood in circumstances 

beyond his control. 

In addition, Article 12(1) of the International Covenant 

on Economic Social and Cultural Rights states: 

The States Parties to the present Covenant 

recognize the right of everyone to the enjoyment 

of the highest attainable standard of physical and 

mental health. 

Finally, the United Nations (UN) Principles for the 

Protection of Persons with Mental Illness and for the 

Improvement of Mental Health Care are generally 

regarded as a benchmark for mental health standards 

of care. 23 

A belief in community responsibility for 

mental health 

We share the perspective expressed in the ACT 

Mental Health Strategy and Action Plan 2003-2008 

that ‘mental health is the responsibility of the whole 

community’. 24 Government, the community sector 

and the general community all have a role to play 

in mental health promotion, prevention and early 

intervention, in addition to continuing care and 

support of people with a mental illness. Extending 

this approach, an acute mental health episode may in 

some cases be seen to reflect a community failure of 

early intervention, promotion and prevention. 

___________________________________________________________________________________________________________________________ 

20 At 5. 

21 At 38. 

22 National Mental Health Plan 2003-8, Australian Health Ministers, Commonwealth of Australia, 2003, at 4. 

23 Other relevant United Nations human rights instruments include, the Declaration on the Rights of Disabled Persons; the Standard Minimum Rules on the Equalisation 

of Opportunities for People with Disabilities and the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care. 

24 Similarly, the ACT Mental Health Strategy and Action Plan 2003-2008 states that ‘mental health promotion and prevention are roles for the whole community and all 

sectors of government.’ At 3. 


12

A belief in the value of coordination, 

partnership and collaboration 

Research demonstrates that effective collaboration 

can have significant resource, organisational, 

referral and service delivery benefits. A core part 

of this paper is an analysis of the potential benefits 

of collaboration and an overview of existing 

collaborative activity in the ACT and elsewhere. 

By doing so, we hope to advance the objective 

expressed in the ACT Mental Health Strategy and 

Action Plan 2003-8, to improve ‘coordination 

between service sectors’. The Strategy identifies ‘the 

development of effective partnerships between the 

mental health sector and other sectors, including 

[general practitioners] GP’s and community 

organisations’ as a key feature of the Action Plan. 25 

It also commits to collaboration between government 

agencies, in identification and early intervention, 26 

stating that: 

Effective partnerships and linkages between 

mental health services and the range of other 

services required by consumers … are integral 

to meeting the mental health care needs of 

consumers. 27 

EXPLORING THE CONCEPT OF COLLABORATION 

Developing an effective integrated service strategy 

requires ‘rigorous thinking’ about the ‘nature, form 

and terms of cross-agency cooperation’. 28 

At a theoretical and conceptual level, some of this 

thinking has begun, with a developing ‘collaboration’ 

literature set. A review of this literature informs the 

following discussion of the definition, objectives, 

types, forms and stages of collaboration. 

Defining collaboration 

Collaboration has been defined as: 

‘a process through which parties who see 

different aspects of a problem can constructively 

explore their differences and search for solutions 

that go beyond their own limited vision of what 

is possible’. 29 

An alternative definition requires that organisations: 

‘develop mechanisms – structures, processes 

and skills – for bridging organisational and 

interpersonal differences’. 30 

The various goals pursued through collaboration 

have been defined in the following categories: 

• creation or modification of service delivery; 

• resource maximisation; 

• policy development at organisational or 

community levels; 

• systems development and change through 

changed relationships between organisations; 

and 

• social and community development aimed at 

strengthening communities.’ 31 

Social service cooperation may be of three different 

types, depending on the organisations involved. All 

of them are essential to ensure the maximum efficacy 

of the social service system. 

Interdepartmental cooperation: This is cooperation 

between government departments. It is critical 

to enable governments to implement ‘whole-ofgovernment’ 

approaches to particular policy issues, 

like mental health. It is also essential to reduce 

___________________________________________________________________________________________________________________________ 

25 At 7. 

26 At 7. 

27 At 39. 

28 Denise Henry, Place Management – A Partnership Approach, NCOSS Conference Paper, 2003, at 2. 

29 Gray, B (1989), Collaboration: Finding common ground for multi-party problems. Jossey Bass, San Francisco at 105, cited by Dr Rae Walker, Collaboration and 

Alliances: A Review for Vichealth, September 2000, published by Victorian Health Promotion Foundation at 1. 

30 Kanter, R.M. (1994) ‘Collaborative Advantage: The Art of Alliances’, Harvard Business Review. July-August, quoted by Dr Rae Walker, Collaboration and Alliances: 

A Review for Vichealth, September 2000, published by Victorian Health Promotion Foundation at 1. 

31 University of Wisconsin – Cooperative Extension (1998), Evaluating collaboratives: Reaching the potential, University of Wisconsin, Madison, cited by Dr Rae Walker, 

Collaboration and Alliances: A Review for Vichealth, September 2000, published by Victorian Health Promotion Foundation. 


• Collaborating: ‘in addition to the other activities 

siloing between departments and its mirroring in 

activities and sharing resources’. 34 they are unlikely to be achieved. Challenges 

the community sector due to segregated funding 

streams. 

described, collaboration includes enhancing the 

capacity of the other partner for mutual benefit 

and a common purpose’. 35 

Interagency cooperation: This is cooperation that 

takes place between two organisations or agencies. 

This might be between two government service 

agencies, for example, the Crisis Assessment and 

Treatment Team (CATT) and Child and Adolescent 

Mental Health Services (CAMHS), or between two 

A particular project or policy initiative may involve a 

number of partners, all with different relationships 

between them, for example, networking, 

coordination, cooperation and collaboration. There 

may be a lead agency principally driving the initiative. 

community sector organisations, for example, 

Appropriate partnerships will require discussion and 

the Mental Illness Fellowship and the Richmond 

the development of dispute resolution forums, the 

Fellowship. This is essential for information and 

forging of a shared vision and common language 

referral networks to be effective, and for jointly 

and possibly also the development of new service 

administered programs. 

delivery models. 36 Recent literature on collaboration 

Intersectoral cooperation: This refers to cooperation 

between different service sectors, for example 

mental health and AOD. It might take place 

between government and/or community agencies. 

For example, a joint project or referral system 

between Directions (a drug and alcohol service) 

and the Mental Health Foundation (which provides 

psychosocial rehabilitation to mental health 

consumers). 

has identified a number of stages in the collaboration 

process, necessary to effective and sustainable 

collaboration. Dr Rae Walker, adapting from the 

earlier work of Gray, identifies three phases in the 

collaborative process: problem setting; reaching 

agreement and implementation. Research around 

effective inter-sectoral collaboration strategies is 

growing and there are now a number of useful 

resources to guide the development of policy and 

practice in this area. For example, VicHealth has 

Collaboration can take a number of forms, varying 

developed a ‘Partnerships Analysis Tool’, ‘a resource 

in the level of cooperation and integration required. 

for establishing, developing and maintaining 

The list of forms set out below is derived from the 

productive partnerships’. 37 

Vicserv, Partnerships Analysis Tool: 

Recent research on collaboration between 

• Networking: ‘exchange of information for 

mutual benefit’. 32 

organisations has emphasised how difficult it is 

to develop and maintain effective collaborative 

• Coordinating: ‘exchanging information and 

altering activities for a common purpose’. 33 

relationships, even where there are adequate 

resources to support the initiative. 38 Unless the 

• Cooperating: ‘exchanging information, altering 

objectives of the collaboration are defined through 

mutual participation and for mutual benefit, 

___________________________________________________________________________________________________________________________ 

32 VicHealth, The Partnerships Analysis Tool: For Partners in Health Promotion accessed at 

http://www.vichealth.vic.gov.au/assets/contentFiles/VHP%20part.%20tool_low%20res.pdf. 

33 Ibid. 

34 Ibid. 

35 Ibid. 

36 Denise Henry, Place Management – A Partnership Approach, NCOSS Conference Paper, 2003, at 3. 

37 VicHealth, The Partnerships Analysis Tool: For Partners in Health Promotion accessed at http://www.vichealth.vic.gov.au/assets/contentFiles/VHP%20part.%20tool_ 

low%20res.pdf. This includes a partnership checklist to be completed before entry into a partnership and during its existence to ensure that the partnership is 

soundly based and continues to function effectively. 

38 Pratt, Pampling and Gordon, (1998) Partnerships fit for purpose? King’s Fund, London, extracted by Dr Rae Walker, Collaboration and Alliances: A Review for 

Vichealth, September 2000, published by Victorian Health Promotion Foundation at i. 


14

to effective collaboration include: poor interpersonal 

relationships between management 

staff, a sense that there is organisational ‘turf’ 

to be defended, efforts to expand a ‘domain’, 

‘professional defensiveness’, ‘status differences’, 

major resource disparities and policy disagreement. 39 

Each relationship between community mental 

health services and different parts of the sector 

varies, raising particular challenges. Consultation 

responses on the issue of inter-sectoral collaboration 

varied depending on the relevant service area, 

organisational structure and philosophy and the 

personal relationships existing between management 

and frontline staff. 

Finally, research on partnerships and collaboration 

generally stresses that not all partnerships should 

move to collaboration. 40 Effective partnerships 

require high levels of trust, a continuing commitment 

to collaboration, the human and financial resources 

to support collaboration at all organisational levels 

and a well-integrated internal organisational 

structure that is conducive to collaboration. 

Reflecting these criteria, the ACT Community 

Facilities Needs Assessment found that increased 

resource sharing was likely to work best where 

organisations have similar structures or functions and 

are co-located. 

There is considerable debate about the possible role 

that government can and should play in facilitating 

community sector collaboration. Some organisations 

expressed the view that a requirement to collaborate 

should be included in government funding contracts. 

The alternative view is that government should 

facilitate and support collaboration, without 

forcing it. Emerging research on partnerships and 

collaboration indicates that collaboration works best 

when voluntary and where there is a pre-existing 

relationship between organisations. This is supported 

by the ACT Community Facilities Needs Assessment 

report conclusion that collaborations work best 

where they are voluntary or self-initiated, rather 

than coerced. 41 This report highlighted the need 

for community organisations to be resourced to 

collaborate. 42 

The concept of collaboration is central to this paper. 

Having established the meaning, forms, benefits 

and challenges of collaboration, this paper seeks 

to determine the extent to which collaborative 

approaches to mental health service delivery have 

developed in the ACT. In doing so, the paper analyses 

cooperative initiatives and projects currently being 

undertaken in the ACT though an examination of 

relationships between different parts of the service 

system. It concludes that, although existing initiatives 

represent a promising starting point, it remains true 

to say that cooperation is proceeding in an ad hoc 

rather than systemic fashion. This paper therefore 

identifies priority areas in which collaboration can be 

improved between parts of the system. In addition, 

it identifies ways in which government can facilitate 

collaborative activity though appropriate support. 

In doing so, it is hoped that this paper might assist 

in the development of a more integrated service 

system with improved outcomes for mental health 

consumers and the community. 

___________________________________________________________________________________________________________________________ 

39 Dr Rae Walker, Collaboration and Alliances: A Review for Vichealth, September 2000, published by Victorian Health Promotion Foundation at 11. 

40 See, for example, VicHealth, The Partnerships Analysis Tool: For Partners in Health Promotion accessed at http://www.vichealth.vic.gov.au/assets/contentFiles/ 

VHP%20part.%20tool_low%20res.pdf. Also see Dr Rae Walker, Collaboration and Alliances: A Review for Vichealth, September 2000. 

41 Ibid. 

42 Stage 1 and 2 of the Community Facilities Needs Assessment 

[PALM (2003)] ACT Community Facilities Needs Assessment (Central Canberra, Belconnen and 

Gungahlin) at 24 and ACTPLA (2004) Community Facilities Needs Assessment: Report for Stage 2 at 35. 


part 2: the relationship between the act community sector 

and the act government 

There are three related aspects to the relationship 

between community services and government 

around mental health discussed in this Part: 

• The funding relationship; 

• Formal inter-agency relationships (i.e. 

memoranda of understanding or MOUs); and 

• Less formal service delivery practices of 

information- sharing, referral and client case 

management. 

All aspects of these relationships should operate 

within the framework of mutual respect established 

by the Mental Health Strategy and Action Plan 

and the ACT Social Compact. This Part outlines the 

government policy context in which the government/ 

community sector relationship takes place. It then 

analyses consultation feedback on various aspects 

of the relationship between government, the 

community mental health sector and individual 

agencies within the sector. 

THE 2003-2008 ACT MENTAL HEALTH 

STRATEGY AND ACTION PLAN 


Plan 2003-8 identifies community organisations 

as ‘a crucial component of the broader mental 

health care system’. 43 It calls for ‘the involvement 

of all government agencies, non-government 

organisations, consumers and carers in working 

towards improving and maintaining good mental 

health in the ACT and across the lifespan.’ 44 In 

addition, it commits to the ‘establishment of a clear 

framework for the role of community organisations 

within the mental health sector.’ 45 This framework 

is consistent with the Third National Mental Health 

Plan, which emphasises the critical role of nongovernment 

organisations (NGOs) in mental health 

A number of items within the ACT Mental Health 

Strategy and Action Plan 2003-8 are designed to 

improve the relationship between government 

departments, government services and community 

sector service providers. For example, Action 7 

calls for consultations to ‘identify the range of 

organisations with whom MHACT currently has, or 

might develop, a partnership to expand the range 

of programs and settings in which preventative 

activity occurs’. 46 Action 25 expresses an intention 

to develop links with non-specialist services accessed 

by those with long term mental health problems. 47 

Similarly, Action 29 pledges to ‘enhance coordination 

between inpatient and community based mental 

health services’. 48 A further series of Actions are 

designed to improve the capacity of accommodation 

providers to support residents with mental health 

conditions. 49 Despite these Action Items, the ACT 

Mental Health Strategy and Action Plan 2003-8 lacks 

detail as to the specific capacities and strengths of 

the community sector and particular mechanisms 

to improve the interface between government and 

community services as well as the integration of the 

community social service system. 

Action 49 states that MHACT is to work with 

specified community organisations to develop 

‘criteria for determining whether resources or services 

are best allocated to the government or community 

sector.’ 50 This process is intended to comprise part 

of a whole-scale review of the current distribution 

of resources in the sector. 51 These criteria have 

not yet been developed, but would be valuable in 

the development of a coordinated and integrated 

service system. However, meaningful community 

participation in the development of the criteria, and 

flexibility in their interpretation and implementation 

are necessary for them to be effective and generally 

perceived as legitimate by the sector. 

service delivery. 

___________________________________________________________________________________________________________________________ 

43 At 59. 

44 The ACT Mental Health Strategy and Action Plan 2003-2008 at 4. 

45 At 7. 

46 At 10. 

47 At 12. 

48 At 75. 

49 See Actions 33, 34 and 35 at 13. 

50 At 15. 

51 Action 50. 


16

THE ACT SOCIAL COMPACT 

Relations 

Government 

the 

commitment 

sector 

roles 

which 

partnership. 

and 

and 

to 

community. 

Social 

marks 

a 

The 

community 

It 

community 

• 

• 

• 

• 

• 

• 

• 

• 

between the community sector and ACT 

should operate within the framework 

ACT Social Compact. The Compact represents 

to partnership between the community 

and government, and outlines their respective 

and responsibilities. The two core principles 

inform the Compact are recognition and 

These principles require mutual respect 

recognition by each sector of the respective 

function of the other, and a mutual commitment 

working together to deliver social services to the 

The Compact, together with the ACT 

Plan and the Community Sector Funding Policy, 

a significant shift from a purchaser/ provider 

partnership relationship. 

Compact defines the role and contribution of 

sector as being: 

… directed to building community involvement 

and participation, addressing social needs and 

strengthening community capacity. 52 

identifies a number of functions which the 

sector fulfils, including: 

Providing community services; 

Playing a role in community development; 

Supporting a range of community and 

leisure activities; 

Enriching community life; 

Providing advocacy; 

Providing pathways for volunteering; 

Contributing to planning and government 

policy development; and 

Supporting and empowering consumers. 53 At the same time, The Compact outlines the role 

and contribution of Government as legislator, policy 

maker, funding body and service provider. It describes 

the relationship between the government and the 

community sector as operating through consultation 

processes, joint policy work, funding arrangements, 

training and the development of new services and 

community initiatives. 54 

Finally, the Compact articulates key principles for 

partnership between the two sectors. Each of these 

principles should underpin government/community 

sector relationships in all areas of engagement. 

However, in the area of community mental health 

services, those most pertinent include: 

• Valuing the distinct and complementary roles 

each sector plays; 

• Respect for the diversity and independence of 

community organisations and groups; and 

• Innovation and continuous improvement in 

community and government processes and in 

the planning and delivery of services. 55 

This paper builds on the Compact’s foundation 

and details the respective roles of government and 

the community sector in the delivery of services to 

mental health consumers. Further, it responds to 

the perception that, despite general commitments 

to a change in mental health policy direction 

and to inter-sectoral collaboration, there is little 

detailed guidance as to how to implement these 

commitments. This paper reflects the community 

sector undertaking in the Social Compact to work 

constructively with government in planning and 

policy development processes. 56 Consistent with 

the relevant undertaking, we have consulted with 

consumers and consumer groups as well as with the 

wider sector and included Indigenous organisations 

in consultations. This paper accurately reflects the 

input we received from independent consultations, 

of 

a 

role 

to 

the 

___________________________________________________________________________________________________________________________ 

52 At 8. 

53 ACT Government, The Social Compact at 8 

54 Ibid at 9. 

55 Ibid at 10. 



and draws upon data collected during the mental 

health service review consultations in addition to 

research literature. 

During consultations we sought to gauge levels of 

understanding of the Compact within the community 

sector. Responses suggested that while there was 

a moderate level of awareness of the existence of 

the Compact, there was little awareness of its detail 

and almost no explicit utilisation of the document. 

That said, several participants indicated that they 

were consciously aware of it, and tried to adhere 

to Compact principles in relationships with other 

government and community organisations. One 

participant expressed the view that it was difficult 

to maintain a ‘Compact relationship’ with MHACT 

due to departmental staff turnover, low community 

sector staff morale and a loss of trust. Indeed, several 

consultation participants expressed the view that 

changes in staff since the formation of the Compact 

had diminished its relevance and government and 

community awareness. Participants noted that the 

ACT Government had provided Compact training 

when it was released, but that this should be 

continuous or periodic, due to staff turnover within 

both the government and community sectors. 

Consultation participants were also asked about 

the perceived potential of the Compact to be better 

utilised, and its specific application to community 

services for people with mental health problems. 

Responses indicated that participants were unclear as 

to how to utilise the Compact at all, though felt they 

probably should be trying to do something with it. 

There was a general feeling expressed that awareness 

around the Compact needed to be raised, particularly 

directed to new staff in government and community 

sector services. 

This paper, drawing from the Compact, seeks to 

encourage inter-sectoral collaboration within the 

community sector, and between the sector and 

government, but also to encourage inter-agency 

integration, cooperation and the elimination of 

departmental ‘siloing’. This is consistent with the 

government commitment to: 

Work towards better integration of policies and 

programs within and across agencies directed 

to specific population groups or needs in the 

community. 57 

This is particularly critical in the area of mental health 

policy, due to the inter-sectoral and inter-agency 

impact of mental health problems. 

AN ANALYSIS OF CURRENT RELATIONSHIPS 

BETWEEN THE ACT GOVERNMENT AND THE 

COMMUNITY SECTOR 

ACT community mental health services have a range 

of relationships with government agencies, ranging 

from funding agreements and formal inter-agency 

agreements to less formal referral and information 

sharing practices. These relationships, forming part of 

a broader service system, are discussed below. 

The funding relationship between the 

ACT Government and community sector 

organisations 

The funding relationship between community 

organisations and the ACT Government operates 

within the framework of the Social Compact, 

the Community Sector Funding Policy and the 

Standard Funding Agreement. Together, these 

documents enshrine principles of mutual respect 

and recognition, partnership funding, collaboration, 

three-year funding cycles, flexibility and quality 

improvement. 

Most community sector organisations consulted had 

a funding relationship with the ACT government. 58 

A number of consultation participants described the 

funding relationship between the ACT government 

and community sector organisations. There was 

a general perception that the community mental 

___________________________________________________________________________________________________________________________ 


58 Some community sector organisations are funded entirely by the Commonwealth government or, less commonly, by independent funding sources. 


18

health sector has long been ‘under-funded’ and 

‘overlooked’ in the allocation of mental health service 

funding. However, on the question of the more 

specific relationship between individual agencies and 

government funding bodies, several organisations 

provided positive feedback, describing open and 

ongoing communication. 

The ACT Mental Health Strategy and Action Plan 

2003-2008 recognised the need for the ‘flexible 

allocation of resources drawn from a range of 

departments and programs’. 59 In addition, the 

Strategy commits the Government to ensure that 

the resource allocation process is both ‘transparent 

and accountable to all stakeholders’. 60 These 

commitments are welcome, though have not been 

fully implemented with consultation participants 

calling for the diversification of funding streams and 

increased funding transparency. 

The burden of accountability reporting was 

consistently identified as a challenge, with 

community organisations concerned that they 

were expected to have public service standards 

of management, without adequate financial and 

logistical support to achieve and maintain these 

standards. 61 Service specifications, performance 

measures and reporting requirements all impose 

a heavy time and human resource burden on 

community sector organisations. This accountability 

burden poses a particular threat to the viability of 

small organisations, who need additional support 

to be able to discharge these obligations without 

detrimentally affecting service delivery. Finally, 

organisations reported the loss of non-core funded 

functions (e.g. innovative program development, 

planning and evaluation, change management, 

research) as a result of outcomes funding. 

The service delivery relationship between 

community and government services: 

formal and informal 

General 

Given the focus of this paper, most of the 

organisations consulted had a primary relationship 

with MHACT rather than other government 

departments. Other organisations providing broader 

services and funded by another department gave 

information about their relationship with MHACT 

to inform discussion of inter-sectoral linkages. By 

contrast, some organisations talked about their 

primary relationship with another Department, for 

example, Housing ACT. 

When asked about their relationship with MHACT, 

community mental health organisations described 

it variously as: ‘improving’; dependant on particular 

staff; ad hoc and focussed on particular clients 

(rather than systemic and permanent), ‘difficult’, 

‘very negative’ and ‘characterised by poor 

communication’. One participant expressed the 

view that her organisation’s efforts to maintain 

this relationship were unreciprocated. Another 

suggested that difficulties arose because of conflict 

between recovery and medical models of service 

delivery. However, several participants described 

a positive relationship with MHACT, particularly 

with policy staff. Others indicated that their referral 

relationship with MHACT was good, but this was not 

a widespread response. Community organisations 

also reported referral links with the government 

housing service, Housing ACT, and some had 

tenancy agreements with Housing ACT for residential 

programs they administered. This kind of partnership 

was seen as vital for the separation of landlord and 

support service. Finally, some participants expressed 

concern and frustration about the poor relationship 

___________________________________________________________________________________________________________________________ 

59 At 59. 

60 At 60. 

61 The Australian Psychiatric Disability Coalition Inc and The Head Injury Council of Australia Inc, Trying Desperately: The Role of Non-Government Organisations in an 

Integrated System of Care for People with Psychiatric Disability or Acquired Brain Injury, Tony Wade and Associates P/L, Brisbane, May 1995 at 6. 


etween MHACT and Housing ACT, perceiving that 

little was changing on the ground despite rhetoric 

about improved inter-departmental cooperation. 

The nature of the relationship between community 

and government mental health services is affected 

by a number of other issues. Principally, these are 

differences in service delivery attitude, approach 

and philosophy. A number of participants described 

the attitude of clinical services towards community 

services in negative terms as ‘arrogant’ and 

‘dismissive’. This perception was reported to translate 

into low staff morale. Some consultation participants 

suggested that relations between community sector 

service providers and government services in the ACT 

compared unfavourably with that in other states 

and territories, and are perceived to be on a less 

equal basis in the ACT than some other jurisdictions, 

despite the Social Compact. 

Definitional differences between the two sectors can 

also pose challenges to cooperation. At a general 

level, the clinical, pathological approach to mental 

health within the clinical sector contrasts with more 

organic concepts used in community services. Some 

community organisations expressed frustration that 

clinical language remained the dominant paradigm 

in the mental health field. Further, definitional 

and diagnosis differences generate gaps in service 

delivery. Examples include individuals with personality 

disorders, those experiencing a serious, though not 

‘severe’ mental health episode and those with a dual 

diagnosis. It was commonly reported that individuals 

experiencing a ‘serious’ mental health episode, 

although posing a potential risk to the individual 

and to the general community, are often not able 

to receive Crisis Assessment and Treatment Team 

(CATT) assistance. This leaves community sector 

organisations facing conflicting duties of care to 

client, employees and volunteers. 

A number of consultation participants highlighted 

this problem, and noted that, upon being discharged 

from their service, clients were only able to access 

CATT assistance after they finally ended up in an 

Emergency Department. Several community 

organisations from outside the mental health sector 

(though potentially overlapping in function with 

this sector) reported that their primary interaction 

with government mental health services was with 

the CATT team. This suggests the need for better 

integrated and improved early detection and 

intervention systems as well as the development 

of crisis support options, for example, step up/step 

down facilities and crisis houses. We welcome the 

recent Government commitment of resources to 

developing a step up/ step down facility. 

Formal inter-agency agreements (MOUs) 

Relations between community sector and 

government services vary in their level of formality. 

Thus, a number of organisations in the mental 

health and alcohol and drug sectors reported 

entering memoranda of understanding (MOUs) with 

MHACT or ACT Health. It should be noted that a 

number of these agreements have been initiated 

by MHACT, which has been welcomed by the 

sector. Of these agreements, some were perceived 

to be working effectively, designating roles and 

responsibilities, referral pathways and protocols for 

service cooperation and joint case management. 

Other MOUs were seen as less effective, either 

due to a lack of awareness of the agreement 

within government services (due to staff turnover 

or perceived departmental attitudes towards the 

sector), or because the protocols of collaboration 

established in the MOU have proven unworkable. 

Low levels of staff awareness about MOUs impedes 

communication and cooperation between services, 

and results in a loss of trust in the Department. Other 

organisations reported that negotiations towards 

an MOU had been abandoned, with each party 

proposing a protocol not acceptable to the other 

party. In some of these cases, parties had managed 

to agree on a protocol in lieu of an MOU. The ACT 

Mental Health Strategy and Action Plan 2003-8 

committed the Government to the development of 

partnerships, the preparation of formal agreements 

and the ‘promotion of the terms and application of 

agreements amongst relevant policy and operational 

personnel within the participating organisations.’ 62 

___________________________________________________________________________________________________________________________ 

62 At 9. 


20

Consultations conducted in the development of 

that Strategy expressed similar concerns about 

staff turnover and awareness of MOUs as those 

expressed in the current consultation process. This 

suggests that further action must be taken to raise 

awareness. Finally, it would be useful for an analysis 

of the impact, benefits and limitations of such MOUs 

to be undertaken, to inform future approaches to 

government and community sector relationships and 

improve the MOU process and framework. 

Joint case management 

Joint case management involves collaboration 

between individual workers or staff teams from 

different services in order to coordinate support 

services for a common client. Consultation 

participants indicated that some joint case 

management occurs with government mental 

health services, but that this is not the norm. This 

is consistent with general comments that there are 

insufficient case managers in MHACT. Some AOD 

services indicated that they were engaged in joint 

case management with MHACT, but there was 

no routine case management for dual-diagnosis 

service-users. Participants made general comments 

about the varying quality and intensity of MHACT 

case management, suggesting that although there 

were some very effective case managers, others 

were thought to either under-manage or overcontrol 

service provision. The variable quality of 

case management impacts upon relations between 

community sector services and government as 

it effects liaison around particular clients and 

relationships of trust. 

those clients deemed eligible and who have been 

referred to MHACT through the triage system. A 

significant amount of feedback was received about 

the current operation of these community teams, the 

general impression being that they were not widely 

available and that case management varied in quality 

and intensity. It was suggested that better protocols 

should be established such that, after an acute 

episode, clinical case managers transfer responsibility 

for care coordination to community health care 

professionals, maintaining links with MHACT, rather 

than withdrawing all case management and support. 

Models in service coordination 

Models in coordinated mental health service 

systems, involving government and community 

services, exist in other states and territories. One 

particularly effective model of coordination is the 

Victorian ‘Primary Care Partnerships’ strategy, which 

links community health, local government and 

specialist providers. 63 The strategy was designed to 

‘create a genuine primary care service system’. 64 It 

requires that each ‘Partnership locality’ prepare a 

Community Health Plan, which, among other things, 

outlines service coordination and identifies service 

partnerships. Partnerships involve voluntary alliances 

of primary care service providers within a defined 

area and aim to strengthen inter-agency coordination 

around ‘needs identification, planning and service 

delivery.’ 65 The Strategy adopts a social model of 

health, and aims to improve promotion, prevention 

and early intervention. 66 The organisations involved 

in the Partnerships include a range of services from 

‘community health and general practice, relevant 

parts of local government, Home and Community 

Care coordination 

Care (HACC) and aged care services, services for 

Care coordination generally involves a key health 

women, indigenous and ethnic people, community 

worker within one service or agency coordinating 

mental health, sexual health and dental services.’ 67 

primary health, mental health and other services 

This model provides an excellent example of 

for a particular client. MHACT has established 

systemic coordination and integration and should be 

community mental health teams, which include 

considered in the development of a strategic response 

team leaders and clinical case managers (generally 

to the issues identified in this paper. 

a mental health nurse). This service is available to 

___________________________________________________________________________________________________________________________ 

63 Vicserv, The development of Psychiatric Disability Rehabilitation and Support Services in Victoria (2003), Part 9. 

64 Department of Human Services (2000), Going Forward: Primary care partnerships, Department of Human Services, Melbourne at 1. 




21 


RECOMMENDATIONS: IMPROVING THE FUNDING, 

FORMAL INTER-AGENCY AND REFERRAL 

RELATIONSHIPS BETWEEN THE COMMUNITY 

SECTOR AND THE ACT GOVERNMENT 

1. Develop inter-departmental service 

agreements to facilitate a wholeof-government 

approach to mental 

health 68 


Plan 2003-2008 commits to the development 

of a ‘range of commitments, agreements 

of memoranda of understanding between 

government departments to support mental 

health within the ACT.’ 69 It proposes the 

development of an Interdepartmental 

Implementation Group, to include 

representatives of government departments 

in addition to the community sector. 70 We 

urge the government to implement these 

commitments as a priority to eliminate service 

gaps, coordinate service delivery and remedy 

the effects of siloing within government and 

community services. The inter-departmental 

relationships between ACT Housing and 

MHACT should be prioritised in this process. 

2. Conduct periodic training in the 

terms and implications of the Social 

Compact and the Community Sector 

Funding Policy for all new staff in 

the government sector, and regular 

information and review forums for 

community sector workers 

In light of consistent comments that staff 

changes in government departments have 

led to low levels of awareness about the 

Social Compact and its implications, the ACT 

Government should undertake to include Social 

Compact training in all orientation processes, 

as well as refresher training for continuing staff. 

The Community Sector Funding Policy should 

also be included in such training. In addition, 

information, review and training sessions should 

be held for community sector staff to inform 

new staff and update continuing staff on 

developments. 

3. Ensure that community participation 

in the development of resource 

distribution criteria is meaningful, and 

that the criteria remain flexible 

Action 49 of the ACT Mental Health Strategy 

and Action Plan states that MHACT is to work 

with specified community organisations to 

develop ‘criteria for determining whether 

resources or services are best allocated to 

the government or community sector.’ 71 

The development of these criteria must be 

a joint endeavour between the government 

and the community sector, and ensure that 

flexibility is retained in the interpretation and 

implementation of the criteria. 

4. Review the impact of MOUs between 

government departments and 

community sector agencies, to improve 

their effectiveness 

A number of MOUs currently exist between 

various government departments and individual 

community agencies, however it is difficult to 

gauge their effectiveness. It is recommended 

that the ACT Government, in cooperation with 

the community sector, review these relationships 

to determine the impact of MOUs on service 

delivery outcomes for service-users. The results 

of such a review should then inform future 

approaches to such relationships, identifying 

current problems with a view to improving 

MOU relationships. 

___________________________________________________________________________________________________________________________ 

68 This recommendation is consistent with Recommendation 1(d) of the Mental Health Council of Australia, Not for Service: Experiences of injustice and despair in 

mental health care in Australia (2005) at 17. 

69 See Action 1 at 61. 

70 See Action 2 at 62. 

71 At 15. 


22

5. Commit to the development, with 

the community sector, of sectoral 

MOUs and consider the adoption of a 

‘Primary Care Partnerships’ model of 

coordinated service delivery 

In order to improve service integration at a 

systems level, ACT Health should re-consider 

the development of MOUs with service subsectors, 

like that previously contemplated for 

the Supported Accommodation and Assistance 

Program (SAAP) sector. Such MOUs have 

the potential to promote collaboration and 

cooperation in service delivery approaches 

for people with mental health issues who are 

service-users of non-mental health services, for 

example, SAAP, community housing and alcohol 

and drug services. Sectoral MOUs also have 

the potential to provide stability in the ongoing 

relationship regardless of staff changes. They 

provide a guide for dealing with common 

clients, an outline of referral procedures and a 

framework for addressing the issues faced by 

those with complex needs. In addition, sectoral 

MOUs can provide a framework for case 

management (identified as an area of unmet 

need) and for cross-sectoral training. Further, 

the ACT Government should explore the 

possibility of developing a model of coordinated 

care informed by the Victorian Primary Care 

Partnerships model. This could provide a 

framework for service coordination and identify 

service partnerships. It could also provide a 

structure within which whole-of-system service 

planning could take place. 


Part 3: The relationship between the community mental health 

sector and other parts of the community social service system 

Introduction 

This Part engages in an analysis of current 

relationships between the community mental 

health sector and other parts of the community 

sector. In doing so, it explores the impact of service 

integration, or the lack thereof, on outcomes for 

service users and the community. Analysis is informed 

by consultations, in which participants were asked 

about the extent to which community services were 

coordinated and linked. Several indicators of service 

linkage were used, including referral and information 

sharing networks, joint projects, formal agreements, 

case management and coordination. These indicators 

formed the basis of consultation questions, and 

are consistent with those frequently used in 

‘collaboration’ literature. 72 

It should be noted that the boundaries of the 

community mental health sector are not fixed, with a 

number of non-mental health specific organisations 

performing functions which fall within the service 

range of the sector, in addition to functions which 

lie outside. For example, a number of organisations 

provide accommodation services in addition to 

mental health services, while others provide a 

range of social, emotional and wellbeing services 

in addition to alcohol and other drug services or 

primary health services. Therefore, the expressions 

‘sector’ and ‘sub-sector’ in this context should be 

understood flexibly. The focus on particular subsectors 

is not intended to reflect a belief that service 

areas need to be considered discretely. Rather, the 

boundaries and transitions between sub-sectors (for 

example, between the mental health and the alcohol 

and other drug sectors) should ideally be seamless 

and the service system well-integrated. 

The need for a coordinated 

system response 

The prevalence of mental illness among service users 

across the spectrum of services was a recurring 

theme in consultations. This is reflected in the priority 

allocated to mental health in the strategic plans of 

a number of non-mental health specific community 

sector peak bodies, as informed by their members 

(e.g. Youth Coalition, ACTCOSS). Conversely, mental 

health consumers who participated in consultations 

indicated that, in addition to mental health services, 

they frequently accessed employment services, long 

term and crisis accommodation services, community 

legal centres (for example, the Welfare Rights and 

Legal Centre), free food services, church welfare and 

crisis services (e.g. Salvation Army), multicultural and 

migrant services and alcohol and drug services. The 

importance of mental health services was recognised 

by all of those consulted from across the community 

service spectrum. This is consistent with the most 

recent Community Sector Survey Report, in which 

survey respondents highlighted health services 

(including mental health and alcohol and drug 

services) as the services most needed by 

their clients. 73 

Consumers who responded to a recent MHCN 

survey indicated that service cooperation and 

knowledge about services was a ‘preferred service 

response’. They identified ‘consistent service 

provision that focuses on maintaining connections’ 

as a preference. 74 In addition, they responded 

that services would be easier to access if ‘good 

networks of services [were] in place including health 

professionals.’ 75 Only 50% of respondents indicated 

that they had been linked with another service 

following their time in inpatient services. 76 

___________________________________________________________________________________________________________________________ 

72 For example, Provan and Sebastian (1998), ‘Networks within networks: Service link overlap, organizational cliques, and network effectiveness’, Academy of 

Management Journal 

41: 453-463 at 460, quoted by Dr Rae Walker, Collaboration and Alliances: A Review for Vichealth, September 2000, published by Victorian 

Health Promotion Foundation at 17. 

73 ACOSS Community Sector Survey 2007 at 87. 

74 ACT Mental Health Consumer Network, Consumer Experiences of Mental Health Services in the ACT: Results of a survey about consumer experiences of mental 

health services, January 2007 at 3. 

75 Ibid at 5. 

76 Ibid at 7. 


24

Failures of service coordination and cooperation 

undermine continuity of care and result in service 

gaps. A number of the service gaps identified by 

participants reflect such failures, including: 

• case management; 

• coordinated dual-diagnosis services; 

• discharge planning; 

• follow-up; 

• PPEI for Indigenous communities; and 

• Dual-disability services. 


identified the need to develop a collaborative 

approach to service delivery for clients with complex 

needs. It should be noted that the Complex Needs 

Working Group was established in 2005 by the 

Implementation Group to research effective ways 

to improve service integration and collaboration. It 

involves members from government and community 

services, in addition to consumers, carers and 

community representatives. The Working Group 

distributed a discussion paper, held a number of 

consultations with stakeholders in March-April 2005 

and has published a final report on consultations. 

Further reform proposals are anticipated. These 

should be taken into account as mental health 

service reforms are progressed. 

Formal inter-agency agreements 

and projects 

Very few community sector organisations indicated 

that they had MOUs, or some other kind of 

formal agreement, with other community sector 

organisations. Similarly, few consulted organisations 

had been involved in joint projects with other 

organisations, with many participants expressing 

scepticism about joint projects, perceiving them to 

be ‘too difficult’ or ‘too time consuming’. Several 

organisations, however, expressed enthusiasm about 

the prospect of being involved in such projects in the 

future. 

Case management 

There was a low level of community case 

management generally reported, with some notable 

exceptions. However, some instances of service 

coordination around particular service-users were 

reported to occur. For example, AOD services 

reported that workers would sometimes initiate 

and maintain contact with a dual-diagnosis client in 

a mental health facility, while some mental health 

and supported accommodation workers indicated 

that they would maintain contact with clients while 

in detoxification. These instances of coordination 

seemed to take place in relation to particular 

individuals rather than as the implementation of a 

service coordination strategy. In another example, 

consumer consultation participants highlighted 

the role that the ACT Disability, Aged and Carer 

Advocacy Service (ADACAS) plays in coordinating 

services for clients (everything from utilities to mental 

health services), but noted that the service was often 

functioning at maximum capacity, and unable to 

assist all those in need. Ultimately, case management 

was consistently identified as a capacity that the 

community sector wishes to further develop. This 

is consistent with the Australian Council of Social 

Service (ACOSS) Community Sector Survey 

finding 

that case management was identified as a priority 

training need. 77 

Referral and information pathways 

All consultation participants indicated that they had 

referral and information relationships with other 

community organisations, either within the same 

sub-sector (for example, mental health) and/or 

between organisations in different sub-sectors (for 

example, primary health and mental health). Some 

engaged in resource-sharing, co-location and joint 

projects, though these activities were less common. 

In many cases, relationships seemed dependant 

on contacts between particular managers or staff 

members, and represented an ad hoc rather than 

coordinated or systemic relationship. The women’s 

sector was an exception, with an agreed pathway 

between services and some commitment to a ‘no 

___________________________________________________________________________________________________________________________ 

77 Australian Council of Social Service, Australian Community Sector Survey Report 2007, ACOSS Paper 145, February 2007 at 92. 


wrong door’ policy. Indeed, despite the existence of 

the links and contacts described above, consumer 

consultation participants perceived that referral and 

information pathways were ‘chaotic’, noting that it 

was particularly difficult to get accurate information 

about the crisis accommodation capacity of other 

organisations. Consumers recounted experiences of 

services being unable to assist them and failing to 

provide them with links to other services. 

An examination of specific 

inter-sectoral relationships 

The relationship between the ACT mental health 

community sector and other areas of the community 

sector varies considerably depending on: 

• the particular sector area; 

• the organisations concerned; and 

• the existence of personal contacts between 

the management and staff of particular 

organisations. 

Some of the primary issues arising around these 

particular relationships are outlined below. 

ALCOHOL AND DRUG SERVICES 

People with a ‘dual-diagnosis’ or ‘co-morbid’ 

condition were consistently identified during 

consultations as a primary area of unmet need. A 

number of organisations suggested that the number 

of dual-diagnosis service-users had increased in the 

last few years partly due to increased use of crystal 

methamphetamine (‘crystal meth’ or ‘ice’), and 

that such cases were often linked to homelessness. 

Services reported that the dual-diagnosis population 

group were frequently ‘shunted’ from service to 

service, and were unable to have all their service 

needs met at any particular time. Although most 

AOD service users with mental health problems can 

be managed by such services, a person with a severe 

mental health condition and a moderate or serious 

drug and alcohol condition may be unable to access 

residential AOD services until their mental health 

condition has stabilised. Likewise, dual-diagnosis 

clients pose challenges for mental health vocational 

rehabilitation services which have strict prohibitions 

on drug use within the workplace. Consumers 

expressed the view that AOD services were easier to 

access, with less of a diagnosis hurdle, than mental 

health services. 

Consultation participants indicated that relations 

between the mental health and the alcohol and drug 

sectors continued to be characterised by a mutual 

lack of awareness, understanding and respect. This is 

despite recent ACT Government initiatives to better 

integrate the two sub-sectors. Such sentiments are 

reflected in the following participant quotes: 

‘Never the twain shall meet’. 

‘Nobody knows who to talk to’. 

Organisations consulted particularly highlighted the 

lack of understanding of problem substance use 

issues by those in the mental health sector. Alcohol 

and drug services consulted suggested that they 

had closer relations with government mental health 

services than community mental health services. 

For example, some joint case management occurs 

between MHACT and AOD community services, 

but little between the community AOD and mental 

health sectors. One participant expressed the view 

that existing case management systems needed to 

be better streamlined. There seemed to be a fairly 

low level of awareness, within both sectors, of the 

particular services and facilities of the other. 

Some community mental health day programs and 

vocational rehabilitation services have a strict policy 

of temporarily suspending service to clients who 

are under the influence of alcohol or drugs. In this 

event, though some indicated that they would liaise 

with relevant AOD services, they did not have a 

standing relationship with the AOD sector. Others 

indicated that they were unaware what happened 

to service users after eviction. AOD services also 

have difficulty supporting dual-diagnosis clients. 

One participant reported that she knew of dual 

diagnosis service users, assessed as mentally stable 

at the time of admission to a detoxification facility, 

who then become extremely unwell over the 

course of several weeks. This can have disastrous 


26

esults for the individual concerned, manifesting 

in an acute mental health episode with the risk of 

self-harm, and requiring an acute service response 

(e.g. from the CATT team). The lack of service 

integration undermines early intervention efforts, and 

ultimately results in poor individual outcomes and 

higher government service costs due to potentially 

preventable acute episodes. 

Difficult service philosophy differences are manifest 

between mental health and alcohol and drug services 

which can raise problems around dual diagnosis 

clients. Some mental health residential services, 

for example, will not permit alcohol or drugs on 

the premises but do not require abstinence for 

continuing participation in the program. In these 

cases, although residents are permitted to use drugs 

off the premises, they can be evicted from services 

for possession of illicit drugs on the premises. Others 

require abstinence for the duration of the program. 

In other services, alcohol and drug use is permitted 

on the premises, provided that this is not interfering 

with the rights of other residents. Conversely, some 

individuals with a mental illness have difficulty 

accessing detoxification services. For example, 

consultation participants reported that clients 

who are self-harming, psychotic or have an eating 

disorder are generally not eligible to be admitted to 

detoxification facilities. 

‘Benzodiazepine’ (‘benzos’) and other 

pharmacotherapies have posed some additional 

service challenges around dual-diagnosis clients. 

For example, some AOD services reported that they 

had service-users on prescribed benzodiazepine 

for mental health conditions, with other 

service-users admitted in order to detoxify from 

benzodiazepine use. This has required a service 

delivery policy that distinguishes between the 

medicated use of benzodiazepine and nonmedical 

use. In other reported cases, clients in 

detoxification programs had sought to detoxify 

from all drugs, including prescription drugs to treat 

Attention Deficit Hyperactivity Disorder (ADHD) 

(like dexamphetamine), which can have negative 

mental health effects. This suggests the need for 

the development of clear mental health and dual 

diagnosis policies and guidelines across the sector, 

to clarify complex treatment and care issues and 

improve service consistency. 

Few organisations provided case management 

services to coordinate services for particular clients. 

However, one AOD service consulted indicated that 

they provided case management and coordinated 

government and community services including 

MHACT, Housing ACT, Medicare, dental health 

services, financial counselling services, Alcoholics 

Anonymous/Narcotics Anonymous and community 

mental health services (e.g. Richmond Fellowship). 

In this capacity, a case manager liaises with other 

services by phone and arranges for support 

workers from other services to visit the client while 

in detoxification, thereby establishing contact 

and support networks before completion of the 

detoxification program. This avoids a ‘service gap 

period’ from developing and facilitates 

continuing care. 

The ACT Government Dual Diagnosis Project (the 

Project) highlighted some of the key service delivery 

issues arising around dual-diagnosis clients, and 

made a series of recommendations for improvement 

of service delivery to this client group. Identifying the 

problems of service segregation, the report stated: 

The separate administration and delivery of 

mental health and alcohol and other drugs 

services poses major problems for a co-ordinated 

and integrated system of care, able to address 

the functional needs of a very vulnerable group 

of citizens. 78 

It is estimated that in the vicinity of up to 80% 

of people with a diagnosed mental illness also 

has a diagnosis of problematic substance use. 

In alcohol and drug services, up to 20% of 

people presenting, are estimated to have a coexisting 

mental illness. Many studies assert that 

___________________________________________________________________________________________________________________________ 

78 Leigh Cupitt, Elizabeth Morgan and Marilyn Chalkley, Dual Diagnosis: Stopping the Merry-go round, prepared for the ACT Department of Health and Community 

Care, April 1999. Accessed at http://www.health.act.gov.au/c/health?a=da&did=10015876&pid=1053605102. 


people with a dual diagnosis are not a separate 

population group, rather they are represented 

in the current client base of existing services, are 

receiving poor services and are generally seen as 

too hard by many professionals. 79 

The Project went on to outline a number of issues 

and problems arising around dual-diagnosis clients in 

the ACT: 

between services and sectors’ would enable the ACT 

to more effectively implement a coordinate dual 

diagnosis strategy. 

In proposing the establishment of a ‘change 

management’ approach to implement a new 

integrated service delivery model, the report rejected 

the proposal to develop a designated dual-diagnosis 

facility, concluding that: 

• access barriers to services from both ACT 

Mental Health Services (ACTMHS) and Alcohol 

and Drug Program (ADP) for both consumers 

and their families; 

• the absence of a co-ordinated and shared case 

management approach with people being 

shunted between services; 

• significant professional differences between 

the two fields, underpinned by different 

professional orientations to treatment and 

support and a limited understanding of the 

respective diagnoses by the other service area; 

• the absence of mechanisms to involve 

consumers and families in service planning and 

evaluation; 

• a lack of respect for consumers; 

• a failure to understand the need for a 

commitment to engagement and long-term 

interventions; 

• limited understanding of and active involvement 

with other sectors including NGOs and the 

private sector services; and 

• a poor understanding of dual diagnosis and 

a lack of adequate and ongoing training. 80 

(emphasis added) 

The Project reported that a number of joint initiatives 

were being undertaken between MHACT and the 

Alcohol and Drug Program (ADP). It argued that the 

size of the ACT population, its compact geographic 

location and the nature of ‘overall good relationships 

There is considerable evidence that specialist, 

stand-alone services are neither the best service 

response nor the most effective or efficient. 

The international evidence suggests that a 

comprehensive, integrated service system which 

brings together mental health and alcohol 

and drug services, working collaboratively 

with consumers, families and non-government 

services, delivers the best outcomes for 

consumers and their families. 

As noted above, the Project, though government 

service centred, acknowledged the importance of 

collaborative engagement with non-government 

services (including Indigenous health services), 

in addition to consumers, carers and general 

practitioners. Nonetheless, consultation participants 

perceived that relations had not significantly 

improved since the Project. One development has 

been the introduction of ‘Getting to know the 

service system bus tours’, which have an emphasis 

on dual-diagnosis, incorporating a number of mental 

health and AOD facilities, organised monthly by the 

Youth Coalition. Though not ‘cooperative’ as such, 

these tours provide an opportunity for community 

sector workers to gain an insight into the variety of 

AOD, mental health and other community services 

available, as well as facilitating interaction between 

workers from different parts of the sector. 


2003-2008 noted that some progress had been 

made with the establishment of the dual diagnosis 

service, but indicated that consultation informants 

emphasised the need for ‘increased training across 

services, closer working relationships and the 

___________________________________________________________________________________________________________________________ 

79 Ibid. 

80 Ibid. 


28

development of clear guidelines of responsibility 

for overall case management.’ 81 The Strategy 

reports that the MOU established between the 

two services goes some way to addressing these 

issues. 82 Finally, the ACT Action Plan for Mental 

Health Promotion, Prevention and Early Intervention 

2006-2008 proposes to ‘extend the collaborative 

approach developed between alcohol and drug 

clinical services for people with a co-morbid illness, 

to develop strategies and services in mental health 

promotion, prevention and early intervention’ with a 

specific Action item to ‘strengthen collaboration’. 83 

This is a welcome and necessary commitment. At 

the end of this Part, a number of recommendations 

are proposed which detail ways in which the 

Government can support community services to 

collaborate. 

HOUSING PROVIDERS AND 

ACCOMMODATION SERVICES 

A number of organisations indicated that 

homelessness was a key issue facing individuals with 

a mental health condition, particularly for youth and 

those with a dual-diagnosis. They indicated that 

there was a current shortage of safe, supported 

accommodation options, particularly for men. The 

relationship between community mental health 

services and community housing providers was 

better than some other inter-sectoral relationships, 

but could be improved. There seemed to be few, 

if any, joint projects between them. That said, a 

strong partnership exists between the Richmond 

Fellowship and Havelock House to provide long 

term accommodation for those with a mental 

illness. Crisis accommodation services were listed 

among those non-mental health services that mental 

health consumers indicated they most commonly 

accessed. Many consultation participants, whether 

service provider or consumer, indicated that a high 

proportion of clients accessing crisis accommodation 

services have a mental illness. Further, a recent 

Mental Health Foundation consultation identified 

the need to develop ‘closer working relations’ with 

emergency accommodation services. 

There are a number of existing links between 

mental health services and crisis accommodation 

services. Firstly, we understand that some crisis 

accommodation services have formal relationships 

with MHACT. Secondly, there are links between 

some crisis accommodation services and the CATT 

team. Crisis accommodation services reported that 

they needed to access CATT services periodically. 

This follows from the fact that many service-users 

will be experiencing an acute situation at the time 

they access crisis accommodation services. For 

this reason, such services can play a vital role in 

early intervention and prevention if linked with 

relevant mental health services. In addition, some 

supported accommodation services also have links 

with AOD services. However, there was a lower 

degree of linkage between accommodation services 

and community mental health services, with few 

protocols existing between the two sub-sectors. 

Finally, the Richmond Fellowship (a mental health 

service provider) and Havelock House (a community 

housing service) have an agreement to provide 

permanent accommodation for people with a mental 

illness. Havelock House provides housing stock, 

while the Richmond Fellowship receives funding to 

support clients in these units. This partnership was 

established in 1997. Apart from resource sharing, 

the partnership serves the particular purpose of 

separating the functions of landlord and support 

services for mental health consumers. In addition, 

it maintains a continuity of tenancy after a mental 

health episode. The program does not receive any 

joint program funding. 

The ACT Action Plan for Mental Health Promotion, 

Prevention and Early Intervention 2006-2008 

proposed that the SAAP and mental health 

community sectors, in addition to rehabilitation 

providers, participate to ‘increase coordination 

___________________________________________________________________________________________________________________________ 

81 At 110. 

82 At 110. 

83 At 24, Action 7.2. 


etween supported accommodation programs 

and vocational and other rehabilitation programs 

to improve access.’ 84 While this is a constructive 

proposal, the need for Government support to 

enhance the capacity of community organisations to 

engage in collaboration and network-building must 

again be emphasised. A more detailed discussion of 

the kinds of support required is developed in the final 

part of this paper. 

EMPLOYMENT SERVICES 

Recent evidence suggests that some three quarters 

of those of working age with a mental illness in 

Australia are not in the labour force. 85 Despite 

this, there are currently only two employment and 

vocational rehabilitation services in the ACT: the 

Mental Illness Fellowship and Workways. Both 

services were consulted during this project and 

indicated that they had effective referral partnerships 

with each other (related to the employment readiness 

of the service user), in addition to relationships 

with other community services. However, there was 

a perception expressed by one organisation that 

relationships between employment or vocational 

rehabilitation services and the rest of the social 

service system are fairly poor, with sub-sectors very 

segregated. Although both organisations outlined 

the key services with which they were linked, 

including mental health support and rehabilitation 

organisations, primary health care services, crisis 

accommodation services and alcohol and drug 

services, most relationships were described as ‘ad 

hoc’, rather than systemic or formal. Interestingly, 

systemic and working relationships were considered 

quite distinctly, with relationships classified as either 

formal, at management level, with no day-to-day 

shared client management or informal, involving 

daily contact around clients. This suggested the need 

to integrate these relationship models. 

Some particular employment issues were identified 

around dual-diagnosis clients. Difficult issues were 

identified in relation to drug and alcohol use in an 

employment context and an employer’s duty of 

care. This suggested the need for closer links to 

be developed between mental health employment 

services and AOD services, to provide the necessary 

alcohol and drug support to enable dual-diagnosis 

clients to maintain or resume employment. Finally, 

due to the narrowing of the role and function of 

Commonwealth job capacity assessors, the need 

for links with other community mental health 

organisations becomes all the more critical. In the 

new Commonwealth policy and funding climate, 

this is the only way that employment services can be 

provided holistically in a context of broader support 

structures. 

PRIMARY HEALTH CARE 

Primary health care services consulted emphasised 

the significant proportion of their clients primarily 

seeking mental health, emotional and social 

wellbeing assistance. This is consistent with the 

Productivity Commission’s recent finding that 11.4 

in every 100 encounters with a general practitioner 

(GP) involves mental health problems. 86 Primary 

health care services consulted included some generic 

health services, in addition to population specific 

services, for example, youth and Indigenous health 

services. What was striking about a number of 

these population-specific services was their holistic 

and non-bureaucratic approach to health. Several 

organisations provided a vast array of services, 

applying a holistic health philosophy that treated 

individuals in all of their particular circumstances 

rather than as belonging to one illness or disorder 

category. In this respect, some organisations were 

models of integrated health care. 

Despite this, some of the services consulted had 

fairly low levels of awareness of relevant community 

mental health services. This is partly explained by the 

fact that they perform an array of services and may 

have less need to refer on to other organisations, 

___________________________________________________________________________________________________________________________ 

84 Action 6.5 at 23. 

85 Council of Australian Governments, National Action Plan on Mental Health 2006-2011, 2006 at 4. 

86 Productivity Commission. Review of Government Service Provision, 2007 at 11.46. 


30

and by the reluctance of some particular population 

groups to access mainstream services. However, 

it also reflects the need for inter-sectoral links to 

be improved and networks to be developed. This 

is necessary as community health services will, in 

certain cases, need to refer clients to specialist mental 

health services. In addition, as referral is a two-way 

path, linkages are essential to ensure that clients 

who do access mainstream services but who could 

benefit from non-mainstream services (for example, 

youth or Indigenous) are connected with those 

services. Finally, the benefits of linkages between 

organisations extend beyond referral pathways, 

opening opportunities for information exchange and 


There have been a number of recent initiatives 

through which primary health care providers have 

sought to establish and improve linkages with 

community services. These have predominantly 

involved general practitioners (GPs) and include the 

ACT Division of General Practice’s Mental Health 

Team; Hospital GP liaison officers; the Can-Do Dual 

Diagnosis Partnership and the TOP Team, opiate 

co-morbidity program. The first of these, the Mental 

Health Team, within the ACT Division of General 

Practice, provides education and training to GP’s 

and practice nurses, implements relevant programs 

in response to new government policy and supports 

GP’s in inquiries about mental health. Secondly, 

GP liaison officers have been located at hospitals 

in the ACT to play a role in patient dischargeplanning. 

Thirdly, the ‘Can Do’ program is a dualdiagnosis 

partnership project between GP’s and 

community sector organisations. Its objective is to 

develop deeper links between community sector 

organisations and particular medical practices. 

It builds on, develops and extends some already 

established links to improve service coordination for 

dual-diagnosis clients. Finally, the TOP Team, within 

the Division of GP’s, runs an opiate co-morbidity 

program, including an Indigenous stream. The 

program coordinates primary health care with alcohol 

and drug services, networking with relevant services. 

Significantly, this includes a number of relevant 

community services, for example, carers groups and 

the Belconnen community program. Part of the role 

of the TOP team is to promote relevant community 

sector services to GP’s, in recognition that lack of 

awareness is a significant obstacle to GP’s referring 

clients to relevant services. Although a constructive 

and significant initiative, consultation feedback 

suggested that much work is still to be done to raise 

awareness about community services, and develop 

closer referral links with GP’s. 

Consultation participants expressed the view that 

GP’s’ level of knowledge of community services 

varied significantly, that there was confusion arising 

around which services were most relevant and 

appropriate for particular client groups and locations. 

The value of personal relationships and contacts 

between GP’s and services was emphasised, so that 

GP’s are able to link clients with services rather than 

merely providing information and contact numbers. 

From the perspective of GP’s, community services 

seem fractured and the system very confusing. 

The Division offers potential to be a vehicle for 

information exchange between primary health 

care and community services. It is able to distribute 

information to community sector organisations 

in newsletters, mail-outs, education forums and 

seminars. This is a cross-sectoral initiative with great 

potential for further development. 

YOUTH SERVICES 

A youth health service consulted estimated that more 

than half of its service-users seek advice and support 

for emotional and mental health related issues. 

Indeed, the youth sector generally identified mental 

health as one of its current strategic priorities. 87 

Youth services are often left to support those youth 

clients with serious mental health problems who pose 

great challenges to services, but are ineligible for 

acute care. Being inadequately trained and equipped 

to provide such support, this takes its toll on staff 

and organisational resources. Youth service advocates 

expressed frustration at generally being overlooked 

___________________________________________________________________________________________________________________________ 

87 This is reflected in the current strategic plans of various youth organisations. 

31 


y the mental health sector, despite providing 

essential support services. The role that youth services 

play in promotion, prevention and early intervention 

at a critical time in an individual’s development was 

perceived to go largely unrecognised by other parts 

of the sector. This results in youth services feeling 

excluded from consultations on mental health issues 

and not being adequately integrated with the rest of 

the service system. 

In addition, youth services and advocates expressed 

concern about the service gap for those between 

18 and 25 years of age. While the youth sector 

provides services to individuals up to 25 years of 

age, mental health sector services generally draw the 

line between childhood and adulthood at 18 years. 

This means that young adults can be inappropriately 

placed in facilities with much older adults. Youth 

services, community mental health services and 

government services should examine issues facing 

this age group in the mental health system with a 

view to developing some initiatives which ensure that 

individuals receive support, care and treatment in an 

age appropriate setting. 

INDIGENOUS SOCIAL SERVICES 

Consultation participants consistently expressed the 

view that Indigenous people are under-represented 

in mainstream service client groups, with many 

exclusively accessing Indigenous services, like the 

Winnunga Nimmityjah Aboriginal Health Service. 

This was explained in terms of cultural difference, 

the fear of judgment and social alienation. One 

consultation participant suggested that without 

workers from an Indigenous service undertaking to 

continue involvement and oversight, clients would 

not agree to access government services, like Child 

and Adolescent Mental Health Services (CAMHS). 


2003-2008 committed the ACT Government to 

supporting the development of links with Indigenous 

communities, to improve the cultural appropriateness 

of mainstream services and support the development 

of an Indigenous mental health workforce. 88 

Consultation feedback suggests that this process 

needs to be advanced as a priority, with some clear 

and effective strategies to make mainstream services 

more accessible to Indigenous communities and 

to improve links between Indigenous services and 

mainstream community mental health services. 

COMMUNITY LEGAL CENTRES AND LEGAL AID 

A significant number of those who access community 

legal centres (CLCs) have a mental health condition. 

This is consistent with what we know of the 

complex causal links between mental illness, poverty, 

homelessness and crime. There is currently no mental 

health specific community legal advice service in the 

ACT. 89 The Welfare Rights and Legal Centre reported 

that mental health consumers most commonly 

seek their advice on a range of welfare related 

legal matters, particularly housing and Centrelink 

entitlements. They also access disability discrimination 

legal advice. Legal Aid represents clients involved 

in Mental Health Tribunal matters in addition to 

individuals with a mental health condition involved in 

criminal matters. Mental health consumers indicated 

that CLCs, like the Welfare Rights and Legal Centre, 

also functioned as critical aids in navigating the 

welfare system and advising on entitlements. The 

CLCs in the ACT have referral links to each other 

and to Legal Aid. They provide information to 

clients about an array of other community services, 

but generally have greater contact with particular 

non-legal services with which there is an established 

relationship. Links between community legal services 

and the broader social service system are mostly ad 

hoc rather than systemic. 

In its submission to the Senate Select Committee on 

Mental Health, the Public Interest Advocacy Centre 

(PIAC) commented on the interface between CLCs, 

mental health services and other services, stating: 

People with a mental illness receive services from 

a range of entities. They may receive pension 

___________________________________________________________________________________________________________________________ 

88 See, for example, Action 18. 

89 This is unlike Victoria, which has a community mental health legal centre. Such a model was considered positively by those consulted, and a need for such a service 

is suggested by consumer feedback that mental health advocacy services in the ACT are inadequate. 


32

payments, they may live in public housing, they 

may use employment agencies, and they may 

access public or private medical services. They 

may also have legal problems and seek legal 

services. PIAC and HPLS [Homeless Persons’ Legal 

Service] lawyers see many people with mental 

illness seeking such services. It is our observation 

that the interface between these services is often 

uneven and leads to a ragged transfer of people 

with mental illness from one service to the next. 

As a result, continuity of care breaks down 

and the individual is then reliant on their own 

resources, which are usually meagre. 90 

This description is consistent with the situation in 

the ACT. The need for broader links between CLCs 

and mental health services is evidenced by the 

high proportion of mental health consumers who 

access community legal services, the high number 

of cases in which no legal remedy is available and 

the importance of connecting often anxious and 

frustrated clients with other services who may be 

able to assist and address the broader social and 

welfare implications of their grievance (for example, 

homelessness due to eviction, poverty due to loss of 

entitlements etc). Individuals with a mental illness 

in such positions of stress are particularly vulnerable 

to an acute mental health episode or ‘falling off 

the edge’ in some other way. The Welfare Rights 

and Legal Centre (WRLC) noted that most clients 

with a mental health condition do not identify 

as such in their contact with an advice service. In 

some cases, it was observed that mental illness 

impaired an individual’s capacity to approach a 

legal process in a focussed and logical way, with 

affected individuals likely to disengage from the 

process out of frustration or lack of motivation. 

CLCs can play an important linking role in the chain 

of services. This potential role is complicated by 

confidentiality obligations which would prevent CLCs 

from contacting other services without the consent 

of a client. However, in situations where a client 

needs and wishes to receive assistance from another 

service, CLCs are able to make contact and refer 

clients on. For these reasons, energy and resources 

should be directed to improving linkages between 

CLCs and other community services, and to including 

CLCs and Legal Aid in relevant cross-sectoral 

networks. 

DISABILITY SERVICES 

There are two key aspects of the relationship 

between mental health and disability services. One is 

the conceptualising of mental health as a psychiatric 

disability, and the second is coordinating dualdisability 

services for clients with a physical disability 

and mental illness (psychiatric disability). 

The conceptual segregation of mental health 

and disability is evident in the ‘siloing’ between 

government disability and mental health 

departments. Participants remarked on the 

segregated bureaucracies and parallel policy 

processes around issues like complex need. Some 

highlighted the intersections between disability, 

mental health and poverty which needed to be 

addressed for housing, disability and Home and 

Community Care (HACC) services. This ‘siloing’ is, 

in many respects, mirrored in the community sector, 

with both the disability and mental health sectors 

regarding themselves as separate ‘sub-sectors’ and 

little service coordination. However, there is some 

movement to reconceptualise mental health as a 

disability for the purposes of policy development, 

advocacy and representation and some alliances 

developing between mental health consumer 

advocacy services and disability advocacy services. 

The shift in thinking around mental health and 

disability is best reflected in the role that ADACAS 

plays in providing individual advocacy services for 

people with physical and/or psychiatric disabilities 

and the aged. 

On the second issue, consultation participants 

highlighted problems around dual-disability clients. 

The Dual Disability Service, a joint initiative between 

Mental Health ACT and Disability ACT, provides 

information and advice to community workers 

working with people with a physical disability and 

mental illness. This is a valuable and welcome 

___________________________________________________________________________________________________________________________ 

90 Public Interest Advocacy Centre, Submission to the Senate Select Committee on Mental Health, 20 May 2005 at 8. 


development, however does not address the 

systemic divide between mental health and disability 

sub-sectors and the resulting failures of service 

coordination. For example, consultation participants 

reported that intellectual disability services will often 

not provide services to people with psychosis, and 

vice versa. Some community sector services expressed 

concern that they did not have the resources to 

deal with dual-disability clients even though these 

clients were sometimes referred to their service. This 

suggests the need for the two sub-sectors to better 

coordinate services, and to develop coordinated dualdisability 

services. A necessary part of this process 

is the development of dual-disability guidelines 

and referral pathways for both mental health and 

disability services, to inform their approach to dealing 

with dual-disability clients. 

RECOMMENDATIONS: IMPROVING THE 

RELATIONSHIP BETWEEN THE COMMUNITY 

MENTAL HEALTH SECTOR AND OTHER PARTS OF 

THE COMMUNITY SOCIAL SERVICE SECTOR 

6. Engage in the mapping of community 

sector service delivery to those 

affected by mental illness, identifying 

service gaps and needs 91 

A service system map should be devised, 

including government and community sector 

services, to identify gaps in service delivery, 

service pressure points (e.g. long waiting lists), 

segregated sub-sectors (i.e. with few or poor 

linkages), priority new services and priority 

innovation areas. We note that the ACT 

Mental Health Promotion, Prevention and Early 

Intervention (PPEI) Project, which commenced in 

2003, engaged in a mapping process of all PPEI 

activity in the ACT. 92 In this recommendation, 

we propose that this initiative be extended to 

address whole-of-service system service gaps 

and network failures. 

7. Fund and facilitate a permanent ACT 

cross-sectoral mental health planning 

network, involving community sector 

service managers, front-line workers 

and mental health consumers 

The ACT Action Plan for Mental Health 

Promotion, Prevention and Early Intervention 

2006-2008 includes a proposal for Government 

and community agencies to: 

‘provide forums for continuing development 

of mental health promotion, prevention and 

early intervention in the ACT through regular 

discussion between sectors connected to mental 

health and the broader community, and regular 

review of progress in implementing the 

PPEI Plan.’ 

In addition, the COAG National Action Plan on 

Mental Health 2006-2011 recognised the need 

to improve referral pathways between services, 

consistent with consultation feedback. 93 

This recommendation develops the above 

proposal, advocating that a network be 

developed of community sector organisations 

involved in mental health service delivery, those 

from related sub-sectors and mental health 

consumers. Government should draw upon 

the expertise of the network in government 

policy planning at all levels. However, the 

network would provide an opportunity for 

community sector managers and workers from 

across the service system to establish contact, 

develop trust, referral networks and linkages. 

It would also be an opportunity for consumer 

input into service coordination strategies and 

models. Research suggests that such networks 

___________________________________________________________________________________________________________________________ 

91 This reflects recommendation 6 of The Australian Psychiatric Disability Coalition Inc and The Head Injury Council of Australia Inc, Trying Desperately: The Role of 

Non-Government Organisations in an Integrated System of Care for People with Psychiatric Disability or Acquired Brain Injury, Tony Wade and Associates P/L, 

Brisbane, May 1995 at 9. This was also recommended by the Human Rights and Equal Opportunity Commission, Report of the National Inquiry into the Human 

Rights of People with a Mental Illness, (1993) (‘Burdekin Report’). This paper is intended to be a contribution to the mapping process, but more detailed research 

needs to be undertaken. 

92 See The ACT Action Plan for Mental Health Promotion, Prevention and Early Intervention 2006-2008 at 31. 

93 At 4. 


34

work most effectively when working towards a 

particular objective. The network would aim to 

facilitate the development of improved referral 

and information networks and collaborative 

partnerships. Ideally, a collaboration expert 

or oversight body should provide assistance, 

working closely with services to educate them 

about the benefits of collaboration, overseeing 

the implementation of policy, monitoring 

strategies, and being accountable for a 

coordinated approach. Its success could be 

managed by qualitative improvements to such 

networks and the number and effectiveness of 

partnerships which develop. The cross-sectoral 

network should include (but not be limited to): 

• Community mental health services; 

Whether the network developed separate 

meetings for managers and frontline workers 

could be left to its determination. It would 

provide an opportunity for managers and frontline 

workers to make contact with each other 

and with counterparts in other organisations. 

Such a network would also provide a forum 

in which discussions about language and 

terminology around mental illness could be held 

and mutual understanding enhanced. 

8. Encourage and support the 

development of collaborations and 

partnerships between community 

sector service providers and with 

government, observing the principles 

embodied in the Social Compact 

• Consumer representatives; 


Plan 2003-2008 commits the ACT government 

• SAAP services; 

to the development of a ‘comprehensive 

• Community Housing providers; 

network of partnerships between organisations 

in the ACT to support mental health prevention 

• AOD services; 

initiatives.’ 94 However, the relevant Action 

• Indigenous services; 

anticipates partnerships between MHACT 

and other organisations, rather than between 

• Women’s services; 

community organisations. 95 We recommend 

that this Action be complemented by a 

• Employment services; 

commitment to support the development 

• CLCs; 

of partnerships between community sector 

organisations. As a general principle, it is our 

• Legal Aid; 

view that partnerships should be voluntary, 

• Youth services and advocates; 

encouraged and rewarded by government 

rather than coerced (for example, through 

• Disability services; and 

funding conditions). We advocate the 

development of incentives to collaboration, 

• GPs. 

necessary to overcome the habitual inclination 

Consultation participants frequently raised the 

need for cross-sectoral forums not only for 

managers but for front-line service workers too. 

Participants indicated that it would be beneficial 

to have face to face contact with other workers 

in the sector, to ‘put names to faces’ and 

develop referral and collaborative relationships. 

to work autonomously (‘we’ve always done 

it this way’) and to counter competitive 

practices. These could take the form of funding 

incentives, logistical support and/or training for 

organisations which engage in coordination 

and collaboration. Training in the management 

of collaboration should be provided to the 

staff member overseeing the collaboration (the 

___________________________________________________________________________________________________________________________ 

94 At 64. 

95 See Action 7. 


‘collaboration tactician’), senior management 

and workers. 96 Organisations would also be 

supported by the development of a partnership 

protocol, like the Partnerships Analysis Tool 

referred to above, tailored to the ACT funding 

and service delivery environment. This should 

include a framework for assessing whether 

a proposed partnership is viable by assessing 

structural, philosophical and geographic 

compatibility. It should provide strategies to 

community sector organisations to manage 

philosophical differences arising during the 

development of collaborative projects. In 

addition, it should allow scope for flexibility 

in the way that organisations implement its 

core principles. 97 Peak bodies should also be 

supported to provide sectoral coordination. 

‘introduce a new system of linking care. People 

within the target group will be offered a clinical 

provider and a community coordinator from 

Commonwealth and/or State and Territory 

government funded services.’ 

The COAG proposal envisaged that ‘community 

coordinators’ would be Commonwealth funded 

personal mentors and helpers or coordinators 

from State and Territory funded services. The 

National Action Plan describes the role of the 

‘community coordinator’ as follows: 

‘The community coordinator will be responsible 

for ensuring the person is connected to the 

non-clinical services they need, for example 

accommodation, employment, education, or 

rehabilitation.’ 98 

9. Fund organisations to engage in case 

management and service coordination 

Consultation participants consistently 

highlighted the lack of case management 

services in the ACT, and stressed the need 

for services to be better coordinated. Clinical 

managers (though too few) play an important 

role but their focus is generally on the 

coordination of government clinical services. 

The perceived fragmentation of community 

Although giving in principle support to the 

COAG proposal, we recommend the extension 

of community coordinators beyond the ‘target 

group’, defined as people with ‘severe mental 

illness and complex needs who are most at risk 

of falling through the gaps in the system.’ 99 

Rather, those with moderate to serious mental 

illnesses should be eligible for case coordination, 

with an information kiosk service available to 

those with low-level high prevalence disorders. 

services, and the shortage of case managers, 

10. Develop clearer protocols around entry, 

suggests the need for specific funding for 

discharge and transfers, between and 

community case managers. These could be 

within the government and community 

based at a number of key services, meeting 

service systems 100 

regularly with each other and other community 

services, providing updated information 

Consultation participants repeatedly raised the 

about the range of services to clients, linking 

slogan of ‘no wrong door’ as an ideal guiding 

clients with relevant services to coordinate 

ethos for the service system. This should 

care and support. This would improve lines of 

be implemented through the development 

communication between organisations, with a 

of clearer protocols around referral, entry, 

dedicated staff member charged with managing 

discharge and transfers into, between and 

relations with a network of relevant services. 

within parts of the service system. As a 

Further, it would be consistent with the COAG 

foundational principle, protocols should define 

commitment to: 

the responsibility of services to link those 

___________________________________________________________________________________________________________________________ 


97 Ibid at 27-8. 

98 Council of Australian Governments, National Action Plan on Mental Health 2006-2011, 14 July 2006, at 5. 

99 Ibid 

100 This reflects recommendations made by the Mental Health Coordinating Council, Building Effective Non Government Mental Health Services in NSW, 15 November 

2005 at 3. 


36

seeking help with other services. Ultimately, a 

culture should be created in which individual 

wellbeing is a service system responsibility, 

borne by each service individually and 

collectively. 

11. Community organisations review 

internal structures to ensure that they 

are supportive of collaboration 

Research indicates that effective cooperation 

requires organisations to have compatible 

internal structures that are conducive to 

collaboration. This might be characterised by 

‘effective internal communication, effective 

internal teamwork, understanding of and 

capacity to provide quality services, and an 

organisational culture that values learning.’ 101 

We recommend that community sector services 

review their organisational structures by 

reference to these criteria as a pre-requisite to 

entering collaborative relationships. 

12. Develop and facilitate an integrated 

dual diagnosis strategy 

All organisations consulted during this project 

indicated that dual diagnosis, or co-morbid 

clients comprised a significant area of unmet 

need in the existing service system. Suggested 

responses to this need varied, from the need 

for a designated dual diagnosis facility 102 , to 

a dual diagnosis step-up/ step-down facility 

accompanied by an outreach team to a systemic 

reform and integration of the mental health and 

AOD service systems. Given the significance of 

the dual-diagnosis client group as proportion of 

mental health and AOD service users, anything 

short of service integration seems like a bandaid 

solution, failing to address systemic and 

causal factors by maintaining service system 

segregation. 

An integrated dual-diagnosis system might be 

developed in a number of ways. Firstly, through 

the creation and improvement of referral and 

information-sharing protocols between the 

two sub-sectors. Secondly, through the crossdisciplinary 

training of staff in both sectors. 

Thirdly, detailed protocols should be developed 

outlining the care and treatment process for 

different kinds of dual-diagnosis clients to take 

into account the varying levels of severity of 

each condition. 103 There are a number of case 

studies from other service systems of both 

designated dual-diagnosis facilities and service 

integration which should be considered in the 

development of an integrated dual-diagnosis 

strategy. 104 

Consultation participants raised concerns 

about the capacity of staff in non-mental 

health services to deal with clients experiencing 

mental health and dual-diagnosis issues. In 

response to this concern, we recommend the 

development of clear mental health and dualdiagnosis 

policies by each service provider from 

across the service system (for example, alcohol 

and drug services, accommodation services, 

community legal services, primary health care 

services, recreational facilities etc). This would 

better prepare staff in such services to respond 

appropriately to mental health consumers 

and dual-diagnosis clients and improve 

consistency in treatment and service delivery. 

This should also include referral guidelines and 

therefore contribute to the development and 

strengthening of community sector service 

networks. 

___________________________________________________________________________________________________________________________ 


102 This view was expressed during the Mental Health Service Review, in the ACT Mental Health Plan, Draft Summary Report of working groups, 16 October, 2006, but 

was also suggested in a number of ACTCOSS consultations with community sector organisations. 

103 This might adopt a four quadrant model for categorising co-occurring disorders, such as that developed by the U.S. National Association of State Alcohol and Drug 

Abuse Directors (NASMHPD) and the National Association of State Alcohol and Drug Abuse Directors (NASADAD) Joint Task Force. 

104 See, for example, Odyssey House Auckland – Dual Diagnosis Program and Family Program, discussed in Lynne Major-Blatch & Kim Fleming, Alcohol and 

Drug Foundation ACT, Report to Alcohol Education & Rehabilitation Foundation: Attendance and presentation of papers at: World Federation of Therapeutic 

Communities Conference, New York, USA; Australian Psychological Society Conference, Auckland, New Zealand and Professional training and development: United 

Kingdom, United States and New Zealand August-September 2006 at 38. For more information, see the Odyssey House website, at http://www.odyssey.org.nz/. 


13. Support the community mental health 

sector to adequately train workers, 

including cross-sectoral training and 

staff exchanges 

Many consultation participants expressed the 

need for increased training for community 

mental health and AOD workers. We 

recommend the development of minimum 

training standards for community mental health 

workers complemented by adequate financial 

and logistical support for organisations to meet 

these standards. In addition, we recommend 

the development of a program of cross-sectoral 

training, particularly for mental health and AOD 

workers around dual-diagnosis clients. Other 

priorities include training for consumers (where 

involved in advocacy, peer support and selfhelp 

work), Indigenous workers and Culturally 

and Linguistically Diverse (CALD) workers. Staff 

placements and exchanges should comprise 

part of any training program, with a focus on 

exchanges between mental health and drug 

and alcohol services as between clinical and 

non-clinical services. 

14. Investigate options to improve 

consumer information services, for 

example, by establishing a central 

information and referral shopfront 

and/or a central telephone information 

line able to provide information about 

government and community mental 

health services. 

Consumers consulted during the project 

highlighted the lack of awareness about 

services as a key impediment to effective 

system-wide service delivery. They called for a 

central information service which could assist 

clients to navigate the service system, with 

up-to-date information on eligibility criteria, 

waiting lists, current services and contact 

details. The idea of a ‘shopfront’, operated by 

the community sector and partly staffed by 

consumers was widely supported among the 

consumer group, who highlighted the problems 

of access to information and service indexes 

quickly becoming out-of-date. This could be 

complemented by an information telephone 

line, to improve client access to information 

and comprise a key part of the ‘no wrong door’ 

approach. 105 These various options should be 

investigated and explored by government. 

15. Develop specific mental health policies 

targeting vulnerable population 

groups, including youth aged 18-25 

years and members of Indigenous and 

CALD communities. 

Some of the problems faced by 18-25 year olds, 

Indigenous and CALD persons in the mental 

health system have been identified in the 

above discussion. In responding to these issues, 

some specific mental health policies should 

be developed in relation to these population 

groups. Firstly, effective and age appropriate 

services need to be developed for 

18-25 year olds. 

Secondly, the need to improve services to the 

Indigenous population was recognised in The 

ACT Mental Health Strategy and Action Plan 

2003-2008. A number of strategies were 

also specified in relation to the Indigenous 

community, with commitments to establish an 

Aboriginal and Torres Strait Islander Mental 

Health Reference Group, place specialist mental 

health staff within Indigenous organisations and 

provide culturally focussed training to specialist 

mental health staff. In addition, the ACT Action 

Plan for Mental Health Promotion, Prevention 

and Early Intervention 2006-2008 identified 

Aboriginal and Torres Strait Islander people 

as a priority population group. The strategy 

outlined a number of actions to be undertaken 

by government and community groups to 

support PPEI for Indigenous peoples. This 

included exploring ‘opportunities to improve the 

collaborative working arrangements between 

Aboriginal specific and mainstream mental 

___________________________________________________________________________________________________________________________ 

105 This reflects a recommendation arising from the ACT Mental Health Plan, Draft Summary Report of working groups, 16 October, 2006 at 2. 


38

health and social and emotional wellbeing 

services, through supported staff exchange 

placements and other strategies.’ 106 Action 

4.4 proposes that the Winnunga Nimmityjah 

Aboriginal Health Service and other Aboriginal 

specific health services, ACT Health and Mental 

Health ACT work to: 

Develop and deliver improved culturally 

appropriate service provision in mainstream 

services, learning from the service delivery 

model at Winnunga-Nimityjah Aboriginal 

Health Service and other Aboriginal-specific 

services. 107 

To advance this Action item, a framework 

for the coordination of Indigenous and 

mainstream services should be developed, 

defining the respective roles of government 

and community services in the implementation 

of mental health policy. We recommend that 

the policy make provision for the recruitment 

and training of additional Indigenous social 

and emotional wellbeing workers to be placed 

in mainstream government and community 

services. In addition, the policy should establish 

mechanisms for these workers to receive 

ongoing professional support in their roles. 

Finally, the ACT Mental Health Strategy and 

Action Plan 2003-2008 recognised the need 

for a specific CALD mental health strategy, with 

an emphasis on early identification. It proposed 

that the government would formalise linkages 

with relevant CALD communities, and provide 

training to these communities and specialist 

mental health practitioners. 108 Consistent 

with this framework, the ACT Action Plan for 

Mental Health Promotion, Prevention and 

Early Intervention 2006-2008 identified CALD 

communities as a priority population group. 

It outlines a ‘population health’ approach to 

mental health in CALD communities which 

‘acknowledges the importance of culture 

and the migration experience in determining 

risk and protective factors that influence 

mental health.’ 109 These initiatives should be 

implemented as a priority, taking into account 

the specific cultural, social and economic 

context in which mental health problems occur 

and developing culturally appropriate support, 

treatment and care service delivery models. 

Community organisations reported that 

the fear of stigma with CALD communities 

currently acts as a critical impediment to early 

intervention. The strategy should address the 

particular perceptions of stigma arising within 

the CALD community around mental health. A 

CALD mental health policy should define the 

respective roles of government and community 

services in its implementation and recognise 

the existing network of multicultural and CALD 

specific community organisations, including 

the Transcultural Mental Health Network, with 

established links to relevant communities. We 

recommend that, in addition to the features 

already identified, the policy make provision 

for the recruitment and training of additional 

CALD mental health workers to be placed 

in mainstream government and community 

services. In addition, the policy should establish 

mechanisms for these workers to receive 

ongoing professional support in their roles. 

___________________________________________________________________________________________________________________________ 

106 Action 4.2, at 20. 

107 At 20. 

108 See Actions 14, 15 and 16 at 68. 

109 At 21. 


conclusion 

This paper has undertaken an analysis of the 

community mental health sector in context. Having 

established the policy and theoretical framework 

in Part One, Part Two examined the relationships 

between community services and ACT government 

departments and services. Part Three then considered 

the intersectoral relationships between community 

mental health organisations and other parts of the 

community social service system. 

The starting premise of this paper is that best 

outcomes for mental health consumers and others 

affected by mental illness can only be achieved with 

service integration and, in particular, intersectoral 

collaboration. This is because of the complex 

relationships between mental illness, poverty, 

homelessness, alcohol and drug use, unemployment 

and other forms of disadvantage. As mental health 

consumers frequently require access to a broad 

range of social and community services, service 

coordination is essential to ensure that the diverse 

needs of service-users are met, and that gaps 

between services and sectors are addressed. 

The purpose of the paper was to evaluate the extent 

to which community mental health services are 

integrated into the broader social service system. 

‘Integration’ has been measured by the extent to 

which referral and information-sharing networks 

exist, as well as the extent to which services 

coordinate, cooperate and collaborate with each 

other. This paper has sought to identify where 

linkages are currently weak or non-existent and to 

make recommendations to address these gaps and 

strengthen these relationships. 

In general, community consultations revealed that 

there is currently little systemic service coordination 

and integration. Linkages that do exist are often 

of an ad hoc nature, or based on individual staff 

contacts rather than entrenched inter-service 

relationships. There are few formal inter-agency 

agreements or joint projects, and no system-wide 

referral protocol exists. That said, some cooperative 

or collaborative initiatives were highlighted, and 

might provide models for other services. However, 

there is a clear need for whole-of-system approaches 

to the complex social issues associated with 

mental illness. 

This paper has taken the position that government 

has a key role to play in developing an integrated, 

collaborative service system. Firstly, by approaching 

relationships with the community sector in the spirit 

of coordination, cooperation and collaboration. 

Secondly, by supporting community organisations 

to collaborate with other community organisations, 

both within and across sub-sectors. A number of 

initiatives have been proposed in this paper by 

which the ACT Government could provide such 

support. In addition, a number of recommendations 

have been made to address service gaps. We urge 

the government and the ACT community sector 

to consider these recommendations, and together 

commit to a ‘no wrong doors’ approach to service 

delivery for those affected by mental illness. 


40

eferences 

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Australian Health Ministers, National Mental Health 

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ACT Health, ACT Action Plan for Mental Health 

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2008, ACT Health, 2006. 

ACT Health, ACT Mental Health Strategy and Action 

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ACT Government, The Social Compact: A partnership 

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Council of Australian Governments, National Action 

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ACT Mental Health Consumer Network, Consumer 

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ACT Planning and Land Authority, Community 

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Andrews, Gavin, ‘The crisis in mental health: the 

chariot needs one horseman’, (2005) 182(8) MJA 372. 

Australian Council of Social Service, Australian 

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145, February 2007. 

Australian Council of Social Service, Submission to 

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Australian Psychiatric Disability Coalition Inc 

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Cuppitt, Leigh, Elizabeth Morgan and Marilyn 

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Henry, Denise, Place Management – A Partnership 

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development: United Kingdom, United States and 

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NSW, 2005. 

Mental Health Council of Australia, Not for Service: 

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care in Australia, 2005. 

Mental Health Council of Australia, Time for Service: 

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41 


appendix a 

CONSULTATION PARTICIPANTS 

FORUM PARTICIPANTS 

MHCC Service Provider forum participants 

Mental health consumer forum participants (13 

attendees) 

INDIVIDUAL CONSULTATIONS 

In person 

The ACT Division of General Practice 

Directions ACT 

Inanna Inc 

The Junction Youth Health Service 

Karralika (ADFACT) 

Mental Health Consumers Network 

Mental Health Foundation 

Mental Illness Fellowship 

Richmond Fellowship 

Winnunga Nimmityjah Aboriginal Health Service 

WIREDD Women’s Information Resources and 

Education on Drugs and Dependency 

Workways 

Youth Coalition 

By phone or email 

ACT Disability, Aged and Carer Advocacy Service 

(ADACAS) 

Welfare Rights and Legal Centre 

Health Care Consumers Association 

Legal Aid 

ACT Health, Mental Health Funding manager 


42

appendix B 

CONSULTATION QUESTIONS 

The unique characteristics and contribution 

of community sector services 

1. What, if anything, do you perceive to be unique 

about community sector service provision? 

2. What, if anything, do you perceive to be 

unique about community mental health service 

provision? What are these services best placed 

to do in the ACT and why? 

Consumer feedback and participation 

3. Do you receive feedback from consumers on 

the effectiveness of your organisation’s services? 

If so, how (e.g. consumers as board members, 

consumer evaluations, participation?) 

The Social Compact 

4. Are you familiar with the Social Compact? If so, 

do you currently utilise the Compact? 

5. How might the sector better utilise 

the Compact? 

6. What specific application do you see the Social 

Compact having on service provision to people 

with mental health problems? 

The service needs of mental 

health consumers 

7. How significant do you assess the number of 

mental health consumers who access your 

service to be? 

8. How do you assess the capacity of your service 

to meet the needs of mental health consumers? 

9. What do you identify as the gaps in service 

provision, or areas of unmet need, in relation 

to mental health consumers accessing social 

services? 

The relationship between the mental 

health sector and other parts of the 

community sector 

10. How do you see the relationship between the 

mental health sector and other community 

sectors (e.g. housing, crisis accommodation, 

supported accommodation, primary health care, 

employment services, education and vocational 

training)? 

11. What linkages exist between your organisation 

or service and other community and public 

services which a mental health consumer 

might need or access (e.g. mental health 

services, housing, crisis accommodation, 

supported accommodation, primary health care, 

employment services, education and vocational 

training)? 

12. Do you have referral links with other 

community, mental health or primary health 

care services? 

13. Are you involved in any projects that are jointly 

funded and/or administered with another 

community organisation? If so, please describe 

and identify any drawbacks and benefits. If not, 

why not? 

14. What processes does your organisation have 

in place when a mental health consumer uses 

your services or seeks your assistance, when 

it is assessed that your service cannot meet 

that individual’s needs? Do you contact other 

organisations? If so, which ones? Do you 

provide information about other services to the 

consumer? 

15. How do you perceive that coordination and 

cooperation could be improved between 

services? What practical strategies might help to 

achieve this? 




16. How do you see the current relationship 

between the community sector services and 

ACT government services in the mental health 

area? 

17. How might this relationship be improved? 

18. More generally, how do you appraise the 

current relationship between the community 

sector and the government (as reflected by, for 

example, funding agreements, funding levels, 

policies, consultation processes etc)? 

Recommendations 

20. What ACT Government commitments are 

needed to improve services to mental health 

consumers and facilitate sector development? 

21. What government policies and funding priorities 

might assist to achieve these goals? 

22. What incentives and initiatives could be 

employed by the ACT Government to enhance 

the effectiveness, coordination and integration 

of services for people with mental health 

conditions? 

Key challenges facing the 

community sector 

19. What challenges do you perceive the 

community mental health sector to be facing? 

Are these challenges the same or different to 

those faced by other parts of the sector (e.g. 

skills shortages, staff turnover)? 


44

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