Final Report – Volume 4: Health care for serving and ex-serving members

Recommendation 61: Establish a brain injury program

Defence and the Department of Veterans' Affairs should establish a brain injury program that covers, at a minimum, relevant Army corps, special forces, Navy clearance divers, Air Force combat controllers, and serving and ex-serving members exposed to mefloquine and/or tafenoquine. The program should:

1. aim to better understand, and mitigate, the impact of repetitive low-level blast exposure on brain processes
2. assess and treat neurocognitive issues affecting serving and ex-serving members, whatever their cause.

To do this, it should:

3. monitor and assess environmental exposure to blast overpressure
4. record members' exposure to traumatic brain injury and minor traumatic brain injury, including in medical records
5. establish a neurocognitive program suitable for serving and ex-serving members experiencing a range of neurocognitive issues, whatever their cause. This could be adapted from the former Mending Military Minds program
6. provide referral pathways for further medical assessment, when required.

Recommendation 62: Establish a research translation centre for defence and veteran health care

The Australian Government should support the development of a research translation centre for Defence and veteran health care, or a similar body with an explicit research translation focus.

1. Defence and the Department of Veterans' Affairs (DVA) should work with relevant stakeholders, including researchers and health providers with expertise and experience in defence and veteran health care, to develop a model for the establishment of the research translation centre and priority initiatives for funding.
2. The model should be informed by the National Health and Medical Research Council criteria for accreditation of a research translation centre, and include the following aims:
   1. promoting and increasing research on Defence and veteran health care in Australia
   2. translating research into improvements to the health system and better outcomes for patients
   3. facilitating collaboration among and between researchers and clinicians
   4. supporting research-infused education and training.
3. Defence and DVA should jointly develop a business case for the research translation centre for consideration by the Australian Government.

Recommendation 63: Reduce stigma and remove structural and cultural barriers to help seeking

The Australian Defence Force (ADF) should identify and remove cultural and structural barriers to help seeking and make a greater concerted effort to reduce stigma. This should include:

1. the Australian Government should remove reference to the word 'malingering' at Section 38 of the Defence Force Discipline Act 1982 (Cth)
2. Defence should review all its policies and procedures and amend or remove those that are stigmatising
3. the ADF should develop a dedicated training program and a communications campaign to reduce stigma and promote help seeking.

Recommendation 64: Establish an enterprise-wide program to monitor and prevent physical and psychological injury

The Australian Defence Force should establish a comprehensive, enterprise-wide injury surveillance and prevention program. The program should encompass physical and psychosocial risks and hazards, and:

1. be adequately resourced, including by engaging staff with appropriate expertise in injury prevention, including physical and psychosocial injury and illness
2. identify the most common injury risks and hazards and implement strategies for preventing or minimising them
3. include functionality within the reporting system to identify root causes or contributing factors including location, time, and activity being undertaken at the time of injury
4. actively monitor where injuries and psychological risks and hazards occur and generate quarterly reports on injury rates and clusters with actionable recommendations for commanding officers.

Recommendation 65: Improve access to, timeliness and quality of mental health screening and use the data effectively

The Australian Defence Force should ensure that its mental health screening continuum effectively identifies members who require additional support and/or who are at heightened risk of suicide, and that these individuals receive support, by:

1. ensuring that members have access to screening and are offered referrals for further support at all known points of vulnerability, including: during ab initio training, when their military employment classification is downgraded, and accessing rehabilitation
2. ensuring that a sufficient and appropriately trained workforce is available to administer the mental health screening continuum and conduct the required follow-ups, including:
   1. ensuring screening is done in such a way that encourages disclosure, including face-to-face screening wherever possible
   2. ensuring members receive timely and appropriate referrals following screenings where required
   3. monitoring the uptake of referrals and following up with members who do not action these referrals
   4. monitoring members who are overdue for screenings and following up with them
3. introducing tools that screen for known risk factors for suicide and suicidality that are not currently screened for, including problematic anger, sleeping difficulties and military sexual trauma
4. using the data collected during screenings for longitudinal surveillance.

Recommendation 66: Where possible, support injured members to be rehabilitated at work, within their home unit

The Australian Defence Force (ADF) should support and resource rehabilitation services within the ADF to adopt a tailored approach, from members rehabilitating within their home unit, either with or without the support of a specialist rehabilitation service working in conjunction with the chain of command when required, to coordination of rehabilitation and recovery through a specialist rehabilitation unit only in exceptional circumstances and when necessary to optimise functioning and return to work.

Consistent with this approach:

1. Defence policies and procedures related to rehabilitation should adopt the principle of recovering at work, where safe to do so. This principle should be embedded in the Defence Health Manual, Military Personnel Manual, ADF Rehabilitation Program Procedures Manual, and other relevant policies and guidelines.
2. rehabilitation at home or in a designated rehabilitation unit should be reserved for exceptional circumstances, and even in these instances, home units must maintain connection with the member undergoing rehabilitation, whether that be at home or assigned to a designated rehabilitation unit
3. rehabilitation outcomes should be publicly reported on a regular basis.

Recommendation 67: Align Defence's clinical governance framework with the national model framework

Defence should work with relevant bodies, including the Australian Commission on Safety and Quality in Health Care and the Royal Australian College of General Practitioners, and in consultation with Bupa, the Department of Veterans' Affairs (DVA) and relevant civilian health services to review its clinical governance framework, with a view to aligning it with the National Model Clinical Governance Framework.

Defence should give particular attention to:

1. strengthening its quality improvement systems to actively manage and improve the safety and quality of its health care
2. ensuring that performance monitoring systems are in place to monitor clinical effectiveness
3. establishing partnerships across DVA, civilian healthcare services and specialist facilities for serving and ex-serving members, and leveraging these partnerships to respond optimally to the unique needs of each patient
4. ensuring that serving members are a partner in the design, delivery and evaluation of Australian Defence Force healthcare services.

Recommendation 68: Strike the right balance between upholding confidentiality and disclosing information when a member is in distress

Defence should ensure that members and commanding officers understand how the Privacy Act 1988 (Cth) operates and the importance of members' consenting to their health information being shared with those able to facilitate appropriate care and support, in the event members are distressed or experiencing mental health challenges.

To this end, Defence should:

1. continue its proactive approach to consent and provide regular training on the Privacy Act
2. regularly evaluate members' understanding of the importance of consent and how Defence will use their personal information
3. by the end of 2025 and regularly thereafter (no less frequently than every three years), review its privacy policy and amend it as appropriate to ensure that it is clear, particularly with respect to:
   1. what it means to provide consent, and why consent is important, particularly for ensuring that family members are equipped with relevant information to support a members' mental health and wellbeing
   2. how members' health information is reasonably necessary for, or directly related to, the functions and activities of the Australian Defence Force (ADF), including what 'suitability for service from a health perspective' means
   3. when a 'general permitted situation' (as defined in section 16A of the Privacy Act 1988 (Cth)) exists in the context of the ADF, particularly when a member is experiencing distress or mental health challenges that puts them at risk of suicidality
   4. when members' mental health information will be disclosed to their commander or manager to facilitate their wellbeing; when, in the context of the ADF, disclosure is necessary to lessen or prevent a serious threat to the life, health or safety of any individual or to public health or safety, and to whom the information can be disclosed.

If barriers remain following review and amendment of the Defence privacy policy, then consideration could be given to subsequent legislative change, as part of the process set out in Recommendation 74.

Recommendation 69: Improve suicide-prevention training so it is practical, tailored, informed by lived experience and delivered in person

The Australian Defence Force should revise and improve its suicide-prevention training so it:

1. focuses on practical rather than theory-based learning, and ensures members are familiar with what support is available
2. is scaled, to emphasise different levels of responsibility, from junior ranks to commanders. Specific training should be offered to senior leaders, which sets out how they can support those under their command
3. is informed by, and involves, members with lived experience of suicide, suicidality or mental health
4. delivers all suicide prevention training in-person by no later than 31 December 2025.

Recommendation 70: Revise protocols for responding to suicidal crisis to be in line with clinical best practice

By no later than 31 December 2025, Defence should revise its protocols for responding to suicidal crisis so they are applied consistently, in line with clinical best practice.

1. The protocols should, among other things, specify:
   1. the availability of, and arrangements for accessing, culturally appropriate crisis care facilities
   2. a minimum standard for aftercare
   3. how monitoring and follow-up support should occur following a suicide-related incident
   4. approaches to reintegration following a suicidal crisis.
2. The revised protocols should be developed in partnership with an external body with expertise in managing suicidal crisis and aftercare.
3. The revised protocols and their application across the three services should be subject to independent evaluation after five years.

Recommendation 71: Increase the Department of Veterans' Affairs fee schedule so it is aligned with that of the National Disability Insurance Scheme

The Australian Government should amend the Department of Veterans' Affairs (DVA) fee schedule to mitigate the challenges faced by veterans in accessing health care, ensuring that:

1. at a minimum, the revised fee schedule aligns with that of the National Disability Insurance Scheme
2. efforts to mitigate supply constraints are prioritised, such as non-fee-for-service components, additional loading, and/or incentive payments, including in areas with few health services for the populations being served.

DVA should reduce the time taken to pay healthcare providers, and track and publicly report on the time taken to provide these payments.

Recommendation 72: Expand and strengthen healthcare services for veterans

The Australian Government and state and territory governments should prioritise networks of care in the National Funding Agreement on Veterans' Wellbeing (Recommendation 88).

To enable this, the Department of Veterans' Affairs (DVA) should develop a plan to expand and strengthen specialised health care for veterans. It should set out how to bring together the different components of the health system to meet the health needs of veterans. DVA should complete the plan by September 2026 and submit it to the Veterans' Ministerial Council for endorsement as part of the funding agreement.

The plan must set out measures to improve the coverage of specialised veterans' care, including by:

1. providing support for primary and allied care providers whose services focus on veterans' health needs
2. expanding veteran-specific secondary and tertiary health services
3. developing additional partnership agreements between DVA and primary health networks.

It must also support the integration of veterans' health services at a local and national level, including by:

4. better informing veterans about available services
5. using existing health infrastructure, such as primary health networks
6. developing local exchanges to tighten relationships between medical and allied health care practitioners.

The plan should be guided by current and future needs and informed by data on Australia's veteran population showing the size of veteran communities in different areas, where specialised services currently exist or are lacking, and how and where veterans access health services.

Recommendation 73: Improve military cultural competency in health professions working with veterans

The Department of Veterans' Affairs (DVA) should complement the work outlined in Recommendation 72 by expanding its efforts to build cultural competency relating to veterans among health workers who operate in mainstream health settings. DVA should expand its training modules and enable health professionals working with veterans to complete them. It should promote this work, including through partnerships with professional bodies.

Recommendation 74: Clarify the application of the Privacy Act to veterans to determine whether amendments are necessary

The Department of Veterans' Affairs (DVA) should seek legal advice clarifying the application of the Privacy Act 1988 (Cth) (and any other relevant legislation) to veterans and their families in the context of sharing data and information related to health, wellbeing and safety.

DVA should use this advice to inform consideration of whether legislative amendments are required to optimise the management of the health and wellbeing of veterans. Consideration may be given to extending the scope of any changes to encompass serving members, if this is needed following the review of the Defence privacy policy proposed at Recommendation 68.

Recommendation 75: Conduct an independent review of Open Arms and publish the report

The Australian Government should commission an independent review of Open Arms, to commence in 2027, following the implementation of the new Model of Care and led by a qualified entity outside of the Defence portfolio.

The scope of the review should be wide-ranging and it should examine:

1. how Open Arms is discharging its functions, including its compliance with clinical standards and its management of at-risk clients
2. issues that could affect Open Arms' ability to discharge its functions, including workforce, culture and funding
3. what functions Open Arms should perform within the wider network of services accessible to serving and ex-serving members
4. the appropriateness of Open Arms' delivery model, and whether another model is preferable.

The Australian Government should make the review's report public.

Recommendation 76: Develop a postvention framework with experts and those with lived experience of suicide bereavement

The Australian Defence Force should develop a postvention framework that must be implemented following a serving member's death by suicide (or suspected suicide) for the purposes of supporting the member's family members and colleagues, as well as first responders. It should involve:

1. collaborating with and seeking input from peak postvention organisations and those with lived experience of suicide bereavement
2. developing communication materials and training modules for commanders and key decision-makers about trauma-informed postvention support for Defence personnel
3. the use of a systematic process for identifying and referring those at highest risk following a suicide death
4. consideration of the unique circumstances of each posting or cultural circumstances of the bereaved
5. greater surveillance and evaluation of the broader impact of suicide on personnel and their functioning for the purposes of improving interventions.

Recommendation 77: Develop a suite of postvention resources in collaboration with stakeholders

Defence and the Department of Veterans' Affairs should fund and facilitate the development of a postvention network of suicide-bereavement resources in collaboration with ex-service organisations, states and territories, lived experience peers, and civilian support organisations to augment current postvention offerings, which can be inclusively accessed by and are tailored for the military community and all those affected by veteran suicide.

Recommendation 78: Prevent, minimise and treat moral injury

Defence and the Department of Veterans' Affairs should work collaboratively to develop an agreed approach to minimising the negative impacts of moral injury, including the risk of suicide and suicidality for serving and ex-serving members. The approach should evolve in line with emerging research and best practice, and at a minimum include:

1. implementing education, training and support programs with the explicit objectives of preventing, minimising and treating moral injury
2. considering using the Moral Injury Outcome Scale or other tools, as the evidence base evolves, to support the early identification and treatment of moral injury
3. conducting or commissioning further research to better understand moral injury in the Australian military population.