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Administration of Mental Health Initiatives to Support Younger Veterans
The objective of the audit was to examine the effectiveness of DVA's administration of mental health programs and services to support younger veterans.
1. Mental health disorders are a major cause of reduced quality of life for many members of the Australian Defence Force (ADF) and veteran communities. Over half the members of the ADF have experienced a mental health disorder at some stage in their lives (54 per cent), which is higher than in the Australian community, where 49 per cent of individuals are estimated to have experienced a mental health disorder.1
2. The delivery of mental health services to eligible members of the ADF and ex service communities is a priority for the Department of Veterans’ Affairs (DVA), as a significant number of disability claims relate to mental health disorders.2 In June 2011, mental health disorders accounted for up to 40 per cent of the total disabilities accepted by DVA as service related.
3. In 2007–08 Australian governments collectively spent $5.1 billion on mental health services, of which $142 million was for DVA programs and initiatives addressing mental health issues.3 By 2009–10, DVA’s expenditure on mental health was estimated to have risen to $160 million.4 While there has been substantial funding of mental health care by all governments in the past 10 years, around 65 per cent of Australians with a mental illness do not access support services.5 A 2010 study of mental health in the ADF suggests this figure is likely to be higher for serving members and veterans, many of whom have indicated a reluctance to report mental health issues due to a concern that it may reduce their prospects of deployment and affect their careers.6 More recently, a former commander of Australian forces in Afghanistan also drew attention to cultural and attitudinal factors that may inhibit ADF members seeking assistance for mental health conditions:
What worries me though is that the vast majority of people coming home hide these problems. No one encourages them to hide them; it’s built into the psyche of the young warrior. They don’t want to admit weakness, and I expect that the inclination to cover this up, pretend you’re OK, will be a continuing one as we bring our troops home from the Middle East.7
4. The profile of the Australian veteran and ex service community has changed over the years with the decline in World War II, Korean War and war widow populations and the emergence of a growing younger cohort. The younger veteran8 cohort includes the estimated 50 000 ADF personnel deployed across the globe since the East Timor deployment in 19999, which marked the beginning of a heightened operational tempo by the ADF that continues to the present day.10
5. Between 4000 and 6000 ADF personnel discharge each year, most of whom are relatively young—the average age of separation for officers is around 34 years, and 27 for other ranks. Many of these young members will have been deployed several times and more than half are married or in long term relationships, and also have children.11 Further, the members of this younger cohort have indicated that they have different needs and expectations compared to their older counterparts (who are the majority of DVA clients), requiring DVA to adapt its programs and services accordingly. DVA has acknowledged that communicating and engaging effectively with the younger cohort is a particular challenge.12
6. The wider mental health environment in which DVA operates is also complex. At the national level, mental health care and services are informed by the Council of Australian Governments’ framework for mental health care in Australia. The framework is working towards a mental health care system that enables recovery, prevents and detects mental illness early, and ensures that all Australians with a mental illness can access effective and appropriate treatment and community support to enable them to participate fully in the community.13 Within the context of the national framework, DVA provides programs and services to support the mental health and wellbeing of members of the ADF and ex service communities. DVA also provides the Veterans and Veterans Families Counselling Service (VVCS), which is a specialised and free counselling service for eligible ADF members, veterans and their families for service related mental health conditions.
7. Since 2001, DVA’s mental health planning and delivery of mental health support services to clients have been guided by its mental health policy framework, Towards Better Mental Health for the Veteran Community14, which DVA has advised is under review. DVA’s approach to mental health issues has also been informed by the considerable body of research since the Vietnam War, which points to enduring and often severe mental health problems experienced by returned and ex service personnel.15 These problems include the long term psychological burden of modern combat16, and the over use of alcohol by the veteran community, which have implications for family cohesion and the reintegration of ADF members into the community.17 Access to, and the availability of, lethal weapons and exposure to combat are also acknowledged risk factors for suicide among veterans.18
8. In addition to the inherent challenges in supporting and facilitating access to appropriate mental health care for eligible members of the ADF and ex service communities with accepted mental health conditions, DVA faces the challenges of: improving mental health literacy so that individuals recognise the need to seek appropriate help for themselves and others; adopting appropriate early intervention and prevention strategies, in conjunction with the ADF; and supporting those ex service personnel whose conditions may manifest years and sometimes decades after they have left the ADF.
9. The objective of the audit was to examine the effectiveness of DVA’s administration of mental health programs and services to support younger veterans.
10. The audit focused on the extent to which DVA has: established an effective management framework to provide mental health services; informed younger members of the ADF and ex service communities about available mental health services and engaged them in the support system; facilitated timely access to well-targeted, integrated mental health care; supported younger veterans with complex needs; and monitored and reported on the performance of mental health programs. The audit did not assess the quality of clinical information and services provided by DVA.
11. DVA delivers mental health services to eligible members of the ADF and ex-service communities19, and develops policy responses to the mental health needs of its clients, in a complex and evolving environment. The profile of mental health disorders and the pattern of usage of mental health services by members of the ADF and ex-service communities differ from that found in the wider community20, reflecting the unique demands of military service and culture. Further, the profile of the veteran community has been changing, with the emergence of a significant younger cohort of veterans, many of whom have served in the numerous ADF deployments of the past decade. The younger cohort of ADF members is particularly at risk of having a mental health disorder, with many of these individuals leaving the military with an undiagnosed and untreated mental health condition.21 These young ex service members are particularly at risk of not receiving the mental health treatment they need, as they do not necessarily maintain links with the ADF or engage with DVA after they leave the military, and they have proven difficult to reach through traditional means such as the ex-service organisations.
12. The Government has commissioned a large body of mental health research and reviews of mental health services, aimed at establishing how best to understand and meet the mental health needs of serving members and the veteran community, particularly the younger veteran cohort.22 DVA’s understanding of the needs and expectations of the younger cohort continues to evolve and the department has begun to draw on this body of work. DVA has also come to recognise the benefit of reviewing and reforming its mental health policy, programs, services and administrative arrangements in light of research and experience.
13. The department has recently revised, or advised of plans to revise, major elements of its mental health administration. In March 2012, DVA established a new Mental and Social Health Branch to improve the coordination and integration of its mental and social health policies. While this is a significant step in improving coordination of DVA’s internal efforts, the department’s mental health policy, programs, services and data systems continue to be managed across many separate business areas and there would be benefit in considering how best to coordinate all of DVA’s mental health effort. There would be particular benefit in considering the merits of assigning responsibility for mental health data policy to the new mental health policy branch, as a means of improving the reliability and accuracy of the department’s mental health data holdings23, which currently underestimate the number of younger veterans with an accepted mental health condition and which will need to be drawn on in the review of DVA’s mental health policy.24
14. The department’s current mental health policy, released in 2001, focuses on the needs of Vietnam veterans, who were the ‘younger’ cohort at that time, and whose accepted mental health claims then accounted for around 55 per cent of new DVA cases. In the past decade, however, the department’s approach to mental health care has been strongly influenced by the needs of a new cohort of younger members.25 The update of the mental health policy framework provides an opportunity for DVA to consider the needs of the emerging younger cohort in a formal way, as well as reviewing the policy’s alignment with national policy frameworks and strategies released since 2001.26 In February 2012, DVA advised that the release of the ADF’s new mental health strategy in 201127 provides an opportunity to update DVA’s mental health policy in 2012.
15. In recent years, DVA has delivered a suite of small, disparate mental health programs and initiatives28 designed to inform younger members of the ADF and ex service communities of mental health care and support services and encourage them to access those services. This strategy has been complemented by initiatives intended to raise awareness of this group’s mental health needs among health professionals, as a means of improving the quality of veterans’ mental health care. A number of these measures were introduced as part of a package of mental health reforms funded through the 2006–07 Budget. Overall, these small programs and initiatives have been of limited effectiveness, with a number of evaluations and reviews highlighting the need for DVA to more effectively target them and related communications activities, as a means of engaging its various client sub groups, particularly younger veterans.
16. These programs have included: three DVA websites designed to improve the mental health literacy of clients and encourage self-help, which have consistently attracted very few ‘hits’29; and voluntary support programs such as the Transition Management Service (TMS) and the Stepping Out program. The TMS was launched in 2000 to support medically discharging members’ transition to civilian life in recognition of the potential stress caused by unplanned separations; and to prioritise and expedite their compensation claims to ensure that these members received their benefits without undue delay.30 DVA’s 2010 younger veteran satisfaction survey found that only 41 per cent of those surveyed, who were eligible to use TMS, had accessed the service. The Stepping Out program was also designed to facilitate a smooth transition from military to civilian life but only attracted 15 per cent of the participants originally anticipated and delivered 17 per cent of the sessions funded by the government.
17. DVA has also sought to improve its communication with health providers, as a means of raising awareness of veterans’ health issues and facilitating access to services by DVA clients—through a shared care model designed to integrate and coordinate service delivery, particularly for clients with multiple health conditions.31 Again, these initiatives have been of limited effectiveness. An evaluation by the Australian Centre for Posttraumatic Mental Health (ACPMH), which surveyed staff and health professionals from 17 Divisions of General Practice sites where DVA had implemented initiatives to promote the shared care model, found that most GPs and other health providers remained unaware of DVA’s initiatives and the range of resources available.32 The evaluation concluded that the cost effectiveness of DVA’s approach to increasing the knowledge and skills of health professionals through peak health bodies was not established and that little evidence in the literature existed to support such an approach.
18. DVA has recognised, for some years, the challenges of communicating with younger members, who tend to have higher expectations than their older counterparts33, and they are more comfortable with online communications platforms and less likely to join ex service organisations—a traditional conduit for communication between DVA and veterans. DVA therefore sought and received funding in the 2006–07 Budget to develop, implement and review its communications and education strategies and commissioned research in 2011 to inform the design of a communications strategy, which was yet to be developed in March 2012. DVA’s Veterans and Veterans Families Counselling Service (VVCS) also received funding in the 2006–07 Budget to develop a targeted communications strategy designed to increase younger veterans’ awareness and use of VVCS services, which similarly has yet to be developed.34 While the communications challenges have long been recognised by DVA and funding made available by the Government, over five years have elapsed since the 2006–07 Budget measures were announced and DVA has made only limited progress in fully implementing them.
19. DVA and the ADF are jointly responsible for providing support to ADF members transitioning from military to civilian life. Effective transition support can be of considerable benefit to veterans. In the case of those with known mental health conditions, it provides information and support relating to available services and benefits. For other personnel exiting the ADF, it can help them understand the possibility that they may develop a mental health condition at some stage in their lives, and inform them of how to access the entitlements35 potentially available to support them. A key risk is that if discharging members are not adequately informed and equipped by the ADF and DVA during the transition process, they are less likely to have knowledge of, and may not access, available services after they leave the military.
20. A key initiative supporting transition, which has not yet been fully implemented, was the launch in 2007 of a whole-of-life framework36, intended to provide comprehensive cross-agency support to individuals from the time of their enlistment through to their resettlement in the community. Documenting the roles and responsibilities of the various agencies in the framework is an essential first step in progressing the initiative, which has yet to be done five years after it was launched. In October 2011, the ADF and DVA implemented new reforms within the whole of life framework, to better support wounded, injured or ill members. The reforms include an on base DVA advisory service, which was implemented after TMS ceased operating.37 While the Support for Wounded, Injured or Ill Program (SWIIP)38 was launched in October 2011, the agreed milestones, reporting mechanisms and performance measures for the initiative were still to be developed in March 2012.39
21. Transition support could be further improved if the ADF were to provide DVA with de identified data, on an annual basis, of the known mental health conditions and deployment patterns of members discharging from the ADF.40 Many members of the ADF continue to be discharged with undiagnosed and untreated mental health conditions, and an appropriate exchange of information would contribute to the development of DVA’s communications and targeting strategies, particularly for members in the groups most at risk of developing mental health conditions.41
22. A targeted approach can be highly effective in managing the needs of clients who are vulnerable, at risk and/or have complex needs. DVA established a Client Liaison Unit in 2007 to actively manage its relationship with such clients42, and a Case Coordination initiative in 2010 to identify and case manage clients at increased risk of self-harm or harm to others. Both programs have been effective in supporting vulnerable clients, and the work of the Client Liaison Unit has been publicly recognised and commended by the Commonwealth Ombudsman and the courts. Nevertheless, there remains scope for the department to improve its administration of vulnerable clients, including through the introduction of quality assurance processes and performance measures, and improved controls to alert staff if a client is being case managed and should not be contacted directly unless authorised.
23. The mental health needs of members of the ADF and ex service communities continue to attract attention and concern in the ADF and wider community43, with many thousands of ADF veterans, including younger members, continuing to return from deployments around the globe. In some cases, veterans will have known mental health needs, while in others, these needs will appear later in life. The current and future needs of these Australians will present ongoing challenges for DVA, working in concert with the ADF. Addressing these challenges will necessarily require a more strategic and coordinated approach than has been in place to date, if DVA is to effectively plan and deliver mental health programs and services that meet both the current and emerging needs of serving and former members.
24. The ANAO has proposed five recommendations to strengthen DVA’s administration of mental health programs and services to better support younger veterans.44 The recommendations focus on: better differentiation between, and understanding of, the various veteran cohorts, particularly the younger groups; evaluating the performance of mental health programs; developing a targeted communication and dissemination strategy to reach younger veterans and members; and measures to improve the integrity of DVA’s mental health data holdings.
Chapter 2—Framework for providing mental health services
25. DVA’s mental health policy framework was endorsed by the Repatriation Commission in 2000 and released in 2001.45 The policy focuses on the needs of Vietnam veterans, who were considered at that time to be the ‘younger’ cohort, and whose accepted mental health claims then accounted for around 55 per cent of new DVA cases.46 In the past decade, however, the department’s approach to mental health care has been strongly influenced by the needs of the emerging cohort of younger members of the ADF and ex service communities. Updating DVA’s mental health policy framework provides an opportunity for the department to review its alignment with national policy frameworks and strategies released since 2001, and to also consider the needs of younger cohorts in a formal way. DVA has advised that the release of the ADF’s new mental health strategy in 201147 provides the opportunity for the department to update its mental health policy in 2012.48
26. The ‘younger veteran’ concept was first used by DVA in the 1990s to differentiate the ‘Vietnam veterans and younger veterans’ from their World War I and II counterparts. However, most Vietnam veterans are now in their 60s and 70s and the ‘younger veteran’ concept is no longer a meaningful descriptor for this group. DVA has also applied the ‘younger veteran’ concept to other veteran cohorts in the post Vietnam war period, to describe veterans aged 45 years and less.49 DVA has acknowledged the difficulties associated with the ‘younger veteran’ concept and is considering the use of an alternative concept such as the ‘contemporary veteran’ group when referring to veterans from recent deployments.50 There would be benefit in DVA clearly identifying the various client cohorts, to strengthen its capacity to engage with different clients51, and for the purpose of planning, identifying trends and undertaking comparative analysis with similar age cohorts in the community.
Chapter 3—Supporting younger members to transition to civilian life
27. The ADF and DVA jointly provide support to ADF members transitioning back to civilian life. Effective transition support can be of considerable benefit to veterans with mental health conditions, by helping them understand the full range of entitlements potentially available to support them and by facilitating their access to appropriate mental health care services. A system of support that is clearly visible to exiting members and their families and which promotes early intervention, prevention and treatment for mental health issues may also assist members who have not sought assistance for mental health conditions while serving to access appropriate care after they have left the ADF.
28. DVA is expected to provide quality and timely services to serving and former members of the ADF, to help the Defence and ex service communities understand the full range of available entitlements, and to assist members to experience a seamless transition on discharge from the ADF.52 Developing better links with the ADF was considered a priority in 2002, as was informing the ADF and ex service communities of their full entitlements and available services.
29. As discussed earlier, the ADF implemented a whole of life support framework in 2007, intended to provide comprehensive, cross agency support to individuals from the time of their enlistment through to their resettlement in the community.53 Increased support and care for young members during the transition process is a priority of the framework. However, younger veterans interviewed by the ANAO were unanimous in their view that once their mental illness rendered them medically unfit for military service, a lack of compassion for their circumstances and the speed of their discharge left them feeling ‘abandoned’ and ‘rejected’ by the ADF.
30. New reforms to better support wounded, injured and ill members, implemented by the ADF and DVA in October 2011 within the whole of life support framework, included an on base DVA advisory service. The focus of the on base advisory service is on outcomes rather than process, with the potential to reduce the complexity often encountered by individuals in accessing the level of support they need. In the context of developing the reporting and performance framework for these reforms, there would be merit in DVA and the ADF jointly developing an evaluation framework for the whole of life approach, including DVA’s on base advisory service.54
31. Between 2001 and 30 September 2011, DVA delivered a voluntary Transition Management Service under agreement with, and on behalf of, the ADF, to provide a higher level of service for members separating from the ADF on medical grounds; including prioritising and expediting their compensation claims so they would receive benefits more quickly.55 As a voluntary program, the Transition Management Service was reliant on the ADF to inform and refer members and therefore required well targeted marketing by DVA to be visible to members. DVA’s 2010 younger veteran survey found that only 41 per cent of those eligible for the Transition Management Service were aware of the service, although 60 per cent of those who did access the service found it useful.56 The ANAO found that there was an inadequate basis upon which to assess the effectiveness or efficiency of the service, due to: inconsistencies in the data collected and reported by DVA and the ADF; the lack of documented records; and the absence of indicators to measure and assess performance and outcomes.
32. The Stepping Out program is a group-based DVA education program designed to facilitate a smooth transition for all ADF members and their partners returning to civilian life. While an evaluation of the program in 2009 found that it was attracting its target audience and stakeholder feedback was generally positive57, it has only attracted 15 per cent of the participants originally anticipated and delivered only 17 per cent of the sessions funded by government through the 2006–07 Budget—arguably due to the way it has been marketed.58 DVA has not addressed the program’s marketing issues but has acknowledged the need for an evaluation of the program’s effectiveness, which is planned for 2012.
Chapter 4—Engaging with key stakeholders
33. DVA consults with, supports and informs the veteran and ADF communities on health issues through a wide range of avenues, including ex service organisations (ESOs), health providers and service delivery agencies.59
34. ESOs have traditionally provided a useful conduit for DVA into the veteran and ADF communities, by eliciting feedback and commentary on issues affecting serving and ex-serving members and their families, including mental health.60 In 2009, DVA established a number of cross organisational consultative forums, with members drawn from key ESOs to continue the work of raising awareness of mental health issues in the veteran community and to improve consultation—in particular, with younger veterans. While ESOs appreciated the opportunities provided by the forums, a number observed that younger members were not represented by the larger, established ESOs who participate in the forums. They indicated that some of the smaller and recently established ESOs are more representative of the views of young members and should be invited to participate in the consultative forums.
35. The Training and Information Program (TIP) is a collaborative program between DVA and ESOs that provides ESO practitioners with training about pensions, welfare and advocacy, to enable them to provide assistance and advice to members of the ADF and ex service communities on compensation and other benefits administered by DVA. DVA reviewed the advocacy and welfare services it supports through the TIP and related programs in 2010, and found that while TIP had been useful in improving the knowledge of many ESO practitioners, there was scope to further improve their knowledge of the more recent legislation61, and the overall consistency of their advice and advocacy services. The review recommended standardising ESO advocacy services and developing a quality assurance system.62 A new and standardised TIP training package was under development during the review and was planned to be rolled out nationally in 2011–12, but DVA subsequently decided not to roll it out in 2011–12.
36. DVA has also sought to improve its communication with health providers.63 The shared care approach is designed to coordinate service delivery by health providers, GPs, the VVCS and the ADF, in order to deliver a more integrated system of care for individual members and veterans who often have multiple health conditions.64 While the shared care approach is consistent with DVA’s mental health policy and the mental health reforms in the 2006–07 Budget65, there was little evidence to suggest that DVA’s interventions had realised an integrated system of shared care across the health system for members of the ADF and ex service communities.
37. In addition to initiatives designed to meet the needs of veterans through third parties—such as ESOs and health professionals—DVA has adopted strategies to support self help by veterans. The internet is playing an increasingly significant role in mental health literacy and the delivery of self help treatments for mental health disorders, particularly for younger members who tend to be more comfortable with internet based services. The development of self help initiatives gained additional momentum through the mental health reforms in the 2006–07 Budget66, which included additional funding for such measures. The ANAO’s examination of three DVA websites67 strongly supports the findings of a DVA sponsored evaluation which concluded that awareness and use of DVA mental health sites is generally low because clients ‘just don’t know about them’.68 The very low levels of site visits were attributed to communication activities that did not appropriately tailor messages to the different demographic groups within the ex service community as a means of raising awareness of the sites.69
38. A number of evaluations and reviews have found that DVA mental health strategies are not always effective in targeting specific messages to the various sub groups within the ADF and ex service communities, particularly the younger cohorts.70 In 2006–07, DVA received $19.7 million through the Budget process to better meet the needs of younger veterans by improving access to preventative and community oriented mental health care. One of the priorities of the measure was the development, implementation and review of communication, awareness and education strategies and the development of a VVCS communication strategy targeting younger veterans. DVA has only partly implemented some of these strategies71, and is yet to undertake the market research to enable the development of an appropriately targeted communication strategy to provide visibility of VVCS and DVA services to younger members.72 DVA commissioned research in 2011 to inform the design of a communications strategy73, which was yet to be developed in March 2012.
39. The importance of effectively marketing DVA services was further emphasised in a 2010 review of the VVCS.74 DVA funded the review to determine the appropriate service delivery model for the VVCS to meet the changing needs of the ADF and ex service communities. The review recommended that DVA develop and implement a marketing plan with targeted strategies to reach the different DVA client cohorts, in order to improve stakeholder engagement and help make the VVCS more visible to the different groups within the ADF and ex service communities.75 Similarly, a recent report on the prevalence of mental health and wellbeing in the ADF identified a need to set up systems to communicate with, and ensure visibility by DVA of, the younger cohort in particular76, during transition and post separation from the military. As a community based provider of mental health care services for the ADF and ex service communities, the VVCS needs to be clearly visible and accessible to discharging members and their families.
Chapter 5—Targeted support to vulnerable clients
40. In May 2007, the Minister for Veterans’ Affairs committed to developing a more proactive approach to managing the relationships between DVA and clients who are vulnerable, at risk and/or have complex needs.77 This followed a Senate Estimates Hearing and a series of inquiries into the circumstances surrounding the suicide of an ex service member in 2006, known as the Gregg Review.78 DVA set up a Client Liaison Unit in 2007, to provide a more holistic service to entitled clients with complex needs who meet certain behavioural criteria.79 Another important service adopted for vulnerable clients was Case Coordination, which was introduced in January 2010 to identify and case manage DVA clients at increased risk of self harm or harm to others. Case Coordination was introduced in response to the important Dunt study into suicide in the ex service community.80
41. Overall, both the Client Liaison Unit and Case Coordination programs have been effective in supporting vulnerable clients who are at risk and/or with complex needs, whose relationship with DVA has either broken down or who have mental health issues that require a more client-centric service. Both the Commonwealth Ombudsman and the courts have publicly recognised and commended the Client Liaison Unit and the support it provides to clients. However, administrative weaknesses were identified in the Client Liaison Unit and Case Coordination programs, including limited documented procedures, a lack of performance indicators and no quality assurance programs. In particular, as both programs provide a primary point of contact into DVA for vulnerable clients with complex needs, all relevant information systems require a reliable facility (supported by the necessary procedural controls) to alert staff of the program’s involvement in the case, prior to their contacting the client. However, where the facility was available it had not been activated in all cases and it had not been implemented in all relevant DVA systems.
Chapter 6—Integrity of mental health data
42. As at 28 June 2011, DVA had identified 107 311 clients in its mental health cohort, of which 50 271 had an accepted service-related mental health disability and 57 040 had received mental health treatment for an accepted mental health condition. The ANAO identified 3748 younger veterans with an accepted mental health condition, but found that the numbers are underestimated and it is not possible to establish DVA’s mental health cohort with any certainty.
43. DVA clients with accepted mental health conditions are provided with a treatment card, either through the Veterans Entitlements Act 1986 (VEA) and/or the Military Compensation and Rehabilitation Act 2004 (MRCA) and these card holders constitute DVA’s mental health cohort. However, many other client groups with mental health conditions accepted by the department are not included in DVA’s mental health cohort, including three groups of significance. These groups are:
- approximately 4000 mainly younger SRCA and MRCA non-card holders with DVA accepted mental health conditions whose treatment is reimbursed by DVA;
- approximately 7000 clients with a recognised and recorded mental health condition but no established liability; and
- the unknown but substantial number of additional clients accessing VVCS and public hospital services.
44. The non inclusion of VVCS data in DVA’s mental health cohort is deliberate. It is intended to demonstrate to members of the ADF and ex service communities that DVA is maintaining the confidentiality of VVCS services.81 However, independent research has recommended the inclusion of VVCS data in a DVA consolidated report82, while still maintaining client confidentiality.
45. DVA’s information technology systems are complex and include a mix of siloed heritage systems and new systems, each with varying levels of functionality. There is consequently a need to replicate data across many DVA systems in order for the old systems to continue to function. The ANAO has previously identified that DVA’s limited documentation and corporate knowledge of its IT infrastructure can make it difficult to identify the source of truth of its data and the ownership within DVA of some data holdings.83
46. DVA has advised that there are difficulties in extracting data that accurately represents its client cohorts, and is considering how it can more accurately report on its mental health cohort and use that information to inform future planning and its new mental health policy.84 To effectively coordinate its internal processes for improving the reliability and accuracy of its mental health data and performance reporting, there would be benefit in DVA assigning clear ownership and responsibility for mental health data.85 As part of a departmental restructure implemented in March 2012, DVA established a dedicated Mental and Social Health Policy Branch to coordinate mental health and social policy issues, and there would be benefit in considering the merits of assigning responsibility for mental health data policy to that unit. 86
47. A copy of the proposed report was provided to DVA for formal comment. Relevant extracts of the proposed report were also provided to the Department of Defence for formal comment. The summary response of both departments is reproduced below.
Department of Veterans’ Affairs
48. DVA agrees with the recommendations of this audit report, three with qualification, as generally confirming some of the directions and initiatives already being undertaken by the department. This includes new approaches to engaging and communicating with veterans from contemporary era conflicts.
49. DVA is one of the largest purchasers of health care in Australia and continues to develop new policies and approaches to service delivery to meet the changing needs of clients. The department is adapting to reducing numbers of ageing clients, increasing numbers of clients from contemporary service (including women and reservists) and the changing needs of both. The department continues to deliver services effectively to its increasingly broad client base, including families and dependents.
50. The department notes that since the audit started in December 2010, there have been significant changes in the management structures and coordination of mental health policy and service delivery in DVA, including a new branch within the department’s structure to enhance client communication capability.
51. This report through its examination of a selection of mental health initiatives demonstrates the complexity of mental health and the need for collaboration with the veteran and ex service communities, research and provider agencies, and other government agencies, including the Department of Defence. This will continue to inform the department’s approach to mental health policy and program development.
52. The department has a comprehensive range of mental health support and treatment available for clients, ranging from prevention and early intervention including online support such as At ease and The Wellbeing Toolbox, primary care, specialised counselling services and treatment, and hospital based care for those who need it including specialised programs for the treatment of post traumatic stress disorder.
Department of Defence
53. As a general comment, with some minor clarifications, the Extract accurately reflects Defence's processes. Defence would also like to note that both Defence and DVA have recently confirmed their commitment to working closely in the support of ADF members and veterans. In particular, Defence and the DVA are working hard to ensure the synchronisation of strategic communications.
 The most common mental health conditions are anxiety, affective disorders (depression) and alcohol disorders: see Hodson, SE, McFarlane, AC, Van Hooff, M, & Davies, C, Mental Health in the Australian Defence Force—2010 ADF Mental Health Prevalence and Wellbeing Study: Executive Report, Department of Defence: Canberra, 2011, p. 5. Some veterans have more than one accepted disorder.
 DVA is part of the Defence portfolio and is responsible for developing, implementing and administering government policy and programs to fulfil Australia’s obligations to the veteran and ADF communities. It provides a range of mental health services to veterans, war widows and widowers, current and former defence force members and their families, and eligible members of the Australian Federal Police with overseas service.
 Department of Health and Ageing (2010) National Mental Health Report 2010: Summary of 15 Years of Reform in Australia’s Mental Health Services under the National Mental Health Strategy
1993–2008. Commonwealth of Australia, Canberra, p. 150. Available from: <htttp://www.health.gov.au> [accessed 29 November 2011].
 DVA has advised that mental health expenditure is currently underreported, particularly in relation to pharmaceuticals.
 Australian Bureau of Statistics, 2007, National Survey of Mental Health and Wellbeing: Summary of Results [Internet], ABS, Canberra. Available from: <http://www.health.gov.au> [accessed 6 April 2011].
 Hodson, SE, McFarlane, AC, Van Hooff, M & Davies, C,  op. cit., pp. 17–19.
 Retired Major-General John Cantwell, ‘Transition is the most dangerous phase’, Lateline, Australian Broadcasting Corporation, 17 April 2012, p. 5. Transcript available from: <www.abc.net.au/lateline/content/2012/s3479770.htm> [accessed 18 April 2012]. See also: Dodd, M, ‘Troops face mental health risks’, The Australian, 19 April 2012, p. 2.
 The ANAO uses the term veteran for ease of reference in the report and consistency with DVA’s terminology. The ANAO notes, however, that younger members of the ADF and ex‑service communities have reported that they do not necessarily identify with this term.
 The Hon Warren Snowdon MP (Minister for Veterans’ Affairs), ‘Address to RSL National Congress’, 20 September 2011, p. 5. Available from: <http://minister.dva.gov.au/media_releases> [accessed 22 September 2011].
 Operational tempo is defined as ‘the rate at which the ADF is able to deliver its operations effects, for example, the rate at which forces are dispatched and the time in which they are turned around for their next task.’ See: Department of Defence, Annual Report 2008–09, p. 372. Available from: <http://www.dva.gov.au/aboutDVA/publications/corporate/annualreport> [accessed 13 April 2012].
 The Hon Warren Snowdon MP (Minister for Veterans’ Affairs), op. cit., p. 3.
 Department of Veterans’ Affairs, Annual Report, 2009–10, DVA, Canberra, 2010, p. 14. A major communication challenge for DVA is that younger veterans are less likely to join ex-service organisations, which have been a traditional means for the department to connect with the veteran community.
 Department of Health and Ageing, National Mental Health Policy 2008, National Mental Health Strategy, DOHA, Canberra, 2009, p. i.
 Department of Veterans’ Affairs, Towards Better Mental Health for the Veteran Community, Mental Health Policy and Strategic Directions, DVA, Canberra, January 2001.
 O’Toole, BI, Outram, S, Catts, SV, and Pierse, KR, ‘The Mental Health of Partners of Australian Vietnam Veterans Three Decades After the War and Its Relations to Veteran Military Service, Combat, and PTSD’, The Journal of Nervous and Mental Disease, Vol. 198(11), 2010, p. 841.
 High combat exposure has been found to correlate with higher levels of anxiety, depression and post‑traumatic stress. See: Sammons, MT, and Batten, SV, ‘Psychological services for returning veterans and their families: evolving conceptualizations of the sequelae of war‑zone experiences’, Journal of Clinical Psychology, 64: 2008, pp. 921–923. doi: 10.1002/jclp.20519.
 Australian Centre for Posttraumatic Mental Health, Psychosocial Rehabilitation for Veterans: Final Report, ACPMH, Melbourne, Victoria, 2010, p. 13.
 Dunt, D, Independent Study into Suicide in the Ex-service Community, January 2009, p. 28. Available from: <http://www.dva.gov.au/health_and_wellbeing/research> [accessed 1 November 2010]. Suicide ideation has been found to be significantly elevated in the ADF compared to the general population, but the number of ADF reported suicides is lower than in the general community. However, the evidence is not conclusive, due to the significant level of underreporting and incomplete reporting Australia‑wide. Also see: Hodson, SE, McFarlane, AC, Van Hooff, M, & Davies, C, , op. cit., p. 10.
 The ADF also has responsibility for, and delivers mental health services to, serving ADF members. DVA has prime responsibility for the delivery of mental health services to the ex‑service community.
 Department of Veterans’ Affairs, Mental Health Update Report, 2008, p. 8.
 Hodson, SE, McFarlane, AC, Van Hooff, M & Davies, C,  op. cit., p. 25.
[22 Two key reports were those prepared by Professor David Dunt in 2009—Dunt, D, Independent Study into Suicide in the Ex‑Service Community, January 2009, and the Review of Mental Health Care in the ADF and Transition through Discharge, January 2009.
[23 A previous ANAO audit recommended that DVA develop an agency‑wide strategy, assigning ownership for data management and integrity issues to business areas. See ANAO Audit Report No. 28 2008–09 Quality and Integrity of the Department of Veterans' Affairs Income Support Records,
 As at 28 June 2011, DVA had identified 107 311 clients in its mental health cohort, but could not establish the younger veteran cohort with any confidence. The ANAO subsequently identified 3748 younger veterans with a mental health condition accepted by DVA. DVA has advised that it is considering how it can more accurately report on its mental health cohort and use that information to inform future planning and its new mental health policy.
 The importance of DVA better understanding and more effectively responding to the needs of the younger cohort was documented in DVA’s corporate documents, including its Strategic Plan, as early as 2002–03. DVA’s capacity to effectively engage and meet the needs of each client group, particularly the younger cohort, would be strengthened by clearly identifying and targeting messages tailored to the various client cohorts.
 The 1992 national mental health policy was still in place in 2001 and was extended in 2008 through a new policy that promoted an integrated, whole‑of‑government response to the improvement of mental health care services through the Council of Australian Governments’ National Action Plan.
 Department of Defence, Australian Defence Force Mental Health and Wellbeing Strategy [Internet], October 2011. Available from: <http://www.defence.gov.au/health/DMH/i-MHRP.htm#13> [accessed 28 October 2011].
 These programs and initiatives are in addition to mental health treatment services.
 These websites are: The Right Mix (delivered at a cost of $330 000 per year); At Ease ($993 475); and Touchbase ($800 000). Delivery costs include the development of supporting paper based resources, and start‑up and maintenance costs.
 The cost of the TMS for the six years to 30 June 2010 was estimated to exceed $4.2 million. The cost of TMS services could not be confidently determined, however, due to inconsistencies in, and incompleteness of, the data reported by the ADF and DVA.
 Funding for shared care initiatives was the major element of a $19.7 million package in the 2006–07 Budget to improve access to preventative and community-oriented mental health care, particularly for younger veterans.
 The evaluation observed that ‘Many health providers expressed surprise at the range of initiatives DVA has developed…[and] there was a level of frustration expressed about the failure of DVA to provide the resources to them’ reflecting a ‘lack of effective dissemination’. Australian Centre for Posttraumatic Mental Health, Evaluation of the Department of Veterans’ Affairs Mental Health Initiatives 2007–2010, Final Report, ACPMH, Melbourne, December 2010, pp. 5 and 79.
 Documented feedback indicates that the younger cohort seeks more streamlined services that meet their immediate needs, and are less accepting of the delays which can arise when processing often complex claims.
 Belsham, S & Associates P/L, Final Report Review of the Veterans and Veterans Families Counselling Service Delivery Model, July 2010, pp. 41–42. This subsequent review of the VVCS in 2010 identified the need for DVA to improve VVCS stakeholder engagement and visibility within the ADF and ex‑service communities. DVA advised in 2011 that it was in the process of developing a general VVCS communications strategy, which does not focus specifically on younger veterans.
 The importance of veterans submitting claims for service‑related injuries early is well understood. See: Haigh, B, ‘Veterans’ Affairs fails many’, The Canberra Times, 25 April 2012.
 The initiative, known then as the Integrated People Support Model, was announced on 23 August 2007 in the CDF/SEC Joint Directive 08/2007, Secretary and Chief of the Defence Force Directive on Support to Our Australian Defence Force Personnel.
 Department of Veterans’ Affairs, Update on Progress of Defence/DVA Links Steering Committee, Ministerial Brief No. B10/0213, 3 March 2010, p.5.
 SWIIP aims to ensure better integration of services and support to prevent injured and ill members from falling ‘through the cracks’. Snowdon, W, (Minister for Veterans’ Affairs), Care for wounded, injured and ill ADF personnel, Defence on the record, Department of Defence, Canberra, 1 August 2011. Available from: <http://news.defence.gov.au/2011/08/01/care-for-wounded-injured-and-ill-adf-personnel/> [accessed 7 October 2011].
 DVA advised that relevant performance measures would only be developed on completion of 20 projects launched as part of the SWIIP.
 ADF information relating to patterns of deployment and service, including the involvement of ADF members in conflict, can provide insights into the various mental health conditions which may affect discharging members in the future.
 The study into the prevalence of mental health in the ADF found: half of ADF members will experience anxiety, affective or alcohol use disorder in their lifetime; one in five members had experienced a mental disorder 12 months prior to interview; the rates of mental disorder were highest in the 18–27 age group; depressive disorders in males and females were significantly higher than the general community (depression is a prevalent outcome following deployment and traumatic exposure); higher rates of Post Traumatic Stress Disorder (PTSD) compared to the general community; the rate of suicidality was more than double that of the general community; and trends showed greater levels of traumatic symptomatology with each deployment.
 The Client Liaison Unit is not considered to be formally part of DVA’s mental health programs because clients are accepted into the program based on their behaviour, not a mental health condition. However, DVA advised that the Client Liaison Unit is within the department’s ‘mental health umbrella’ because the difficulties reflected in clients’ relationship with DVA may overlay acute mental health problems.
 See: Haigh, B, ‘Veterans’ Affairs fails many’, The Canberra Times, 25 April 2012; Le Grand, C, ‘The Black Dog of War’, The Australian, 26 April 2012, p. 13; Lateline, Australian Broadcasting Corporation, ‘Transition is the most dangerous phase’, 17 April 2012, p. 5; and Dodd, M, ‘Troops face mental health risks’, The Australian, 19 April 2012, p. 2.
 The recommendations do not address clinical treatment services, which have not been examined in the audit.
 The intention of DVA’s mental health policy was to: guide the department’s future planning and development of mental health care and services; improve the integration and coordination of mental health services within DVA; and improve mental health care for veterans and their families, through a collaborative approach with DVA’s key partners, such as the Departments of Health and Ageing and Defence. Department of Veterans’ Affairs, Towards Better Mental Health for the Veteran Community, DVA, Canberra, January 2001, p. 1.
 ibid., pp. 5–7. In June 2011, Vietnam veterans with accepted mental health disabilities accounted for approximately 30 per cent of DVA’s total mental health treatment population.
 Department of Defence, Australian Defence Force Mental Health and Wellbeing Strategy [Internet], October 2011. Available from: <http://www.defence.gov.au/health/DMH/i-MHRP.htm#13> [accessed 28 October 2011].
 DVA originally advised the ANAO in December 2010 that its mental health policy was under review at that time.
 DVA defines younger veterans as those aged 45 years and less for the purpose of surveying their views, but uses a range of different definitions of younger veterans for various purposes. The VVCS has also adopted its own definitions of ‘younger veterans’ for various purposes—with one definition referring to younger veterans as those below 35 years of age and another referring to younger veterans as those below 50 years.
 While the concept of a ‘contemporary’ veteran or group may temporarily overcome some methodological issues, it too is a relative concept. Further, it does not differentiate between the younger and older members of the ‘contemporary’ cohort, whose ages may range from late adolescence to the mid‑fifties.
 Australian Centre for Posttraumatic Mental Health, Pathways to care in veterans recently compensated, Creamer, M, Hawthorne, G, Kelly, C, Haynes, L, Melbourne, 2004, p. 114.
 Department of Veterans’ Affairs, Rehabilitation and Compensation Business Redesign, Blueprint, Version 0.4, Final Draft, 16 December 2010, p. 3.
 Departments of Defence and Veterans’ Affairs, Joint Working Group Submission to the Defence/DVA Links Steering Committee, Future Support to ADF Members, Version 1.0, 5 February 2010, pp. 2–5.
 Further, the provision of de‑identified data to DVA, on an annual basis, of the known mental health conditions and deployment patterns of members discharging from the ADF, would enable DVA to better identify, monitor and support high risk groups, and would inform DVA’s future planning, particularly its communications and targeting strategies for members in the high risk categories.
 Departments of Defence and Veterans’ Affairs, Joint Working Group Submission to the Defence/DVA Links Steering Committee, Future Support to ADF members, Version 1.0, 5 February 2010,
 However, 40 per cent had reported not finding the service so useful, which was consistent with other evidence acquired during the audit that suggested the quality and service delivery of the Transition Management Service varied depending on location and could have been improved.
 Australian Centre for Posttraumatic Mental Health, Stepping Out Program, Evaluation of the pilot program rollout, ACPMH, Melbourne, September 2009, p. 7.
 A review conducted in 2009 indicated that Stepping Out is not well known by the ADF, could be better promoted and the focus of its marketing as a psycho‑social program may be off‑putting for some members. See: Dunt, D, Review of Mental Health Care in the ADF and Transition through Discharge, 2009, p. 22. Defence has subsequently advised that ADF Transition Centres provide members with information and scheduled dates regarding Stepping Out program events.
 Arrangements for engagement include formal inter‑agency protocols, service level agreements and other strategic arrangements, transition services, the Veterans’ Affairs Network and service centres, quarterly newsletters, targeted information and marketing materials, websites and various cross‑agency consultative forums.
 ESO representatives are mainly volunteers supporting the veteran and ADF communities regarding pension and compensation‑related claims and appeals, as well as welfare support, referral and information. DVA funds the training and administrative costs of ESOs to provide pension and welfare‑related advice and support to members.
 The 2010 review of the ESO advocacy and welfare services found that ESO practitioners have fairly widespread knowledge and understanding of the Veterans’ Entitlements Act 1986 (VEA) and its compensation focus, but are less comfortable with the more recent Safety, Rehabilitation and Compensation Act 1988 (SRCA) and the Military Rehabilitation and Compensation Act 2004 (MRCA), and the emphasis they place on rehabilitation.
 Department of Veterans’ Affairs, Review of DVA-funded ESO Advocacy and Welfare Services, DVA, Canberra, December 2010, p. 85. The review also considered that a holistic approach to supporting practitioners would include TIP training, mentoring and on-the-job training.
 In order to raise the profile of DVA with health providers, the department has focused on: shared mental health care coordination strategies; educating health providers about the needs of veterans; and facilitating access by DVA clients to appropriate community‑based mental health care through a shared care model.
 Multiple health conditions are also known as co-morbidities and may include a combination of physical and/or mental health conditions.
 Both emphasise the benefits of coordinated and integrated mental health care.
 Department of Veterans’ Affairs, New Policy Proposal—Young Veterans Branch and VVCS Branch, Explanatory Notes, DVA, Canberra, 2007, p. 6.
 The three websites were The Right Mix, At Ease and Touchbase.
 Australian Centre for Posttraumatic Mental Health, op. cit., p. 115.
 The Hon Warren Snowdon MP (Minister for Veterans’ Affairs), New program to strengthen Defence families, Media Release, Parliament House, Canberra, 23 August 2011. Available from: <http://minister.dva.gov.au/media_releases/2011> [accessed 7 October 2011].
 The ANAO’s analysis found that it was not possible to conclude that any of the VVCS 2006–07 Budget initiatives examined had fully achieved their stated outcomes.
 Effective communication of the full range of benefits, including access to health services under the three compensation schemes administered by DVA, is a key means of supporting serving and former members of the ADF. The findings of the 2010 study into the prevalence of mental health and wellbeing in the ADF also reinforce the importance of effectively providing information relating to mental health services, as a means of supporting members with mental health conditions.
 Orima Research, A report on qualitative communications developmental research about mental health literacy, Department of Veterans’ Affairs, Canberra, 28 July 2011, p. 4.
 The VVCS provides case management and group programs for mental health issues related to military service or peace keeping operations as well as assisting with lifestyle, health and family matters.
 Belsham, S & Associates P/L, Final Report Review of the Veterans and Veterans Families Counselling Service Delivery Model, July 2010, pp. 41–42.
 Hodson, SE, McFarlane, AC, Van Hooff, M. & Davies, C, , op. cit., p. xxxii.
 Standing Committee on Foreign Affairs, Defence and Trade, Budget Estimates, Thursday 31 May 2007, pp. 118–139.
 The three‑part review into the circumstances surrounding Signaller Gregg’s death comprised: an independent inquiry into his deployment and management of his transition/discharge arrangements; the handling of Signaller Gregg’s DVA compensation claims and Comsuper’s military superannuation benefits; and the whole‑of‑government approach to handling his case. Available from: <http://www.dva.gov.au/health> [accessed 17 January 2011].
 Department of Veterans’ Affairs, Policy and Procedures Manual, Client Liaison Unit, p. 42.
 Dunt, D, Independent Study into Suicide in the Ex‑service Community, January 2009.
 The VVCS is a confidential counselling service which DVA administers separately from its other services, to provide assurance to VVCS clients that disclosures made to VVCS counsellors will not inform DVA decision‑making processes relating to claims.
 DVA Mental health Datamart, Implications and recommendations for policy and planning, undertaken for DVA’s Mental Health Policy Unit by the ACPMH, 9 November 2006, pp. 4 and 20. DVA already has data exchange protocols in place to share de-identified data with external providers.
 ANAO Audit report No. 28 2008–09 Quality and Integrity of the Department of Veterans' Affairs Income Support Records, pp. 17–18.
 DVA client groups missing from its mental health cohort include public hospital admissions and treatments (especially in rural and remote locations where there are limited mental health services), VVCS clients, serving ADF members with accepted conditions, MRCA and SRCA non card-holders (many of whom are in the youngest cohort), and clients receiving new mental health treatments in the previous nine years.
 DVA advised that a departmental restructure implemented from 1 March 2012 would contribute to the development of a more consistent approach to mental health data reporting.
 A previous ANAO audit recommended that DVA develop an agency‑wide strategy, assigning ownership for data management and integrity issues to business areas. See: ANAO Audit Report No. 28 2008–09 Quality and Integrity of the Department of Veterans' Affairs Income Support Records,