The Australian Government has taken a bold step to address suicide by establishing one of the world’s first dedicated National Suicide Prevention Offices (NSPO). Led by Dr Michael Gardner, the NSPO has a whole of government remit placing greater emphasis on the social determinants of health as a preventive strategy.
The traditional approach of treating suicide as a health portfolio and, even more specifically, a mental health focus, often at the point of crisis, mischaracterises the problem, said Dr Gardner. “What this means is our response is unlikely to be successful.” To begin exploring the correct approaches will take the government’s understanding that it’s not just a mental health issue and it’s not just a health issue. “It’s much more broad and much more complex.”
While suicide rates in Australia are not among the highest in the world, the Australian Government has shown a single-minded commitment to reducing the impact on the community. The decision to take this bold step was strongly influenced by recommendations in the report from the National Suicide Prevention Special Advisor, by advocacy from peak bodies and people with lived experience, all of whom wanted to see a greater emphasis on the social determinants of health. This was reinforced by a particularly powerful statistic—the disparity between Indigenous and non-Indigenous Australians. Controlling for socio-demographic factors such as housing, education and employment accounts for 74% of disparity.
These influences resulted in the decision for the NSPO to work across all portfolios of government to initiate policies that would reduce the origins of the occurrence of suicidal behaviours. Adopting this approach recognises that real suicide prevention must address, for each individual, the unique combination of social, economic, historic, health and mental health circumstances that underlie their particular situation.
This broad approach is not without its critics. Advocates question whether the emphasis on the social determinants will be at the expense of supporting the healthcare system to improve its care for people presenting with suicidality.
Dr Gardner said there are three reasons why the focus on prevention will not undermine effective healthcare:
- Funding for social determinants does not come from the health portfolio. The likelihood of a government using investments in education or housing as a justification to reduce health expenditure is extremely low.
- Investing in the social determinants aims to reduce drivers of distress. It prevents people from requiring mental health care in the first place, freeing up capacity and resourcing in the mental health system.
- Integrating the social determinants into the healthcare system and enabling services to address the underlying drivers of distress means that mental health support is actually going to become more effective. The incidence of re-presentation will reduce.
“I really don’t see any tension between the social determinants and the healthcare system in practise,” he noted. “They are very much complementary. The objective is to keep people from becoming suicidal in the first place, provide effective care and practical, social and circumstantial support. “Doing any one of those things alone is not going to see the difference we want to see in suicide rates.”
Limited in its own resources, the NSPO has nine staff and a modest financial budget, its capability will be extended far beyond those resources by operating as a hub and guided by a number of working groups with deep expertise in suicide prevention. The Advisory Board is supported by the working groups, including the governance and social policy areas, the state and territory jurisdictions that deliver services in suicide prevention, some discipline-specific groups and an expert review panel. The membership of these working groups adds to the depth of knowledge and expertise in suicide prevention needed to flesh out the National Strategy, the first task of the NSPO.
Keeping an eye on the work of the NSPO will be the Lived Experience Partnership Group (LEPG), arguably one of the most important advisory groups to bring their knowledge and expertise to the work of the NSPO.
Susan Edgar, chair of the LEPG, said the group has the responsibility to ensure that activities of the NSPO are released with meaning and purpose based on lived experience. “We are a group of 14 people with diverse experiences and backgrounds as well as geographic spread across the country,” she explained. This enables the group to provide unique and diverse insights and knowledge to the work of the NSPO. “What is exciting is that lived and living experience is front and centre of the developing strategy.”
Both Dr Gardner and Susan know from personal experience that addressing the drivers of suicidal behaviour is a key factor in prevention. The shift upstream to build population-level protective factors is a new direction for suicide prevention in Australia. Previous National Plans have been criticised for not putting greater emphasis on prevention. They have maintained a narrow focus on mental health services and the crisis end of the spectrum. This means care has not looked at the person as a person, with a variety of experiences and history in circumstances, but simply as a health presentation, a medical presentation.
However, one possible consequence of the whole of government approach taken by the NSPO is workforce capacity. Potentially there could be increased demand for people with lived and living experience to be actively involved in communities and workplaces responding to policy decisions arising from the strategy.
Susan Edgar noted that it’s a challenging concept and one the group has not yet addressed as it is very early days. “The LEPG was formed towards the end of last year and our role is to feed into the NSPO,” she said. The group’s focus will be to consider how government policy will impact people and suicidality and rates in the community. “Unless the impact of policy decisions is considered at the coalface, we won’t achieve our vision of preventing suicide.”
It also raises the question of workforce capacity and not just for those with lived and living experience. As with many other countries, Australia is facing mental health workforce shortages and Dr Gardner said this is a serious issue facing the NSPO. “ There are significant structural questions in relation to the suicide prevention workforce, and we will develop a workforce strategy as a subsequent piece to the National Strategy,” he shared. First, the scope of the suicide prevention workforce must be defined. Then the office needs to provide clarity on the roles and determine the skill sets and the funding mechanisms required. “It is insufficient to train or attract workers; we need to sustain and embed them into systems with funding, supervision and ongoing development.”
The decision to form the NSPO with its focus on coordination is supported by research from Professor Stephen Platt and colleagues. In an article published in the Crisis journal in 2019 National Suicide Prevention Strategies – Progress and Challenges, they note the importance of national strategies is gaining consensus on the important and essential components of a suicide prevention system. But they also state that “effective implementation is key to achieving the strategic objectives and outcomes. There are several challenges or barriers to successful implementation including:
- limited knowledge, capacity, or capability among partners about how to change working practices, in order to deliver interventions;
- ineffective planning, coordination, or collaboration between delivery partners;
- a mismatch between inputs (resources, equipment, or personnel) and the ambition, demands, and outcomes of the strategy;
- an unsupportive political, social, or legal environment; and
- limited capacity to monitor implementation progress and make necessary adjustments.
The authors also noted the paucity of published studies or reports on these topics. As a result, “policy makers, practitioners, and researchers working in suicide prevention across the globe have learned little about the process of implementing national strategies and even less about their effectiveness and cost-effectiveness.”
Much of the success of the NSPO hinges on the ability to persuade and influence governments across Australia to adopt the National Suicide Prevention Strategy and support its implementation. Australia has a federated system of government, so implementation will be both important and challenging. Once the National Strategy is in place, the NSPO will have a role in monitoring and tracking individual jurisdictional governments. It will see where people are falling through the gaps in the system and can then hold governments to their commitments.
Fortunately for the NSPO Australian governments are very committed in a bipartisan way to suicide prevention which gives the leadership of the NSPO cause for optimism. “Discussions to date have been met with genuine goodwill and enthusiasm,” said Dr Gardner. “We are in a very fortunate place in Australia to be in that position where everyone is enthusiastic and willing to work in a coordinated way.”
Sue Murray, International Correspondent
A health promotion advocate in Australia dedicated to improving the health and well being of all people. Throughout her career, she has focused on health for the community and has expertise in communications, education, and organisational development.
Sue currently leads the Zero Suicide Institute of Australia, which aims to support the healthcare system to understand and more effectively manage those who are vulnerable to suicide and suicidal behaviour.