PART SIX: ANALYSIS OF SUBMISSIONS AND FORUMS AGAINST THE NATIONAL STANDARDS FOR MENTAL HEALTH SERVICES

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6.4 SOUTH AUSTRALIA

• 6.4.1 STANDARD 1: RIGHTS
• 6.4.2 STANDARD 2: SAFETY
• 6.4.3 STANDARD 3: CONSUMER AND CARER PARTICIPATION
• 6.4.4 STANDARD 4: PROMOTING COMMUNITY ACCEPTANCE
• 6.4.5 STANDARD 5: PRIVACY AND CONFIDENTIALITY
• 6.4.6 STANDARD 6: PREVENTION AND MENTAL HEALTH PROMOTION
• 6.4.7 STANDARD 7: CULTURAL AWARENESS
• 6.4.8 STANDARD 8: INTEGRATION
• 6.4.9 STANDARD 9: SERVICE DEVELOPMENT
• 6.4.10 STANDARD 10: DOCUMENTATION
• 6.4.11 STANDARD 11: DELIVERY OF CARE
• 6.4.12 STORIES OF HOMICIDE AND SUICIDE IN SOUTH AUSTRALIA

ANALYSIS OF SUBMISSIONS AND CONSULTATIONS FROM SOUTH AUSTRALIA AGAINST THE NATIONAL STANDARDS FOR MENTAL HEALTH SERVICES

In summary, information presented in this section was gathered from 31 submissions (see Appendix 8.3.4) and presentations made at community forums attended by approximately 120 people (see Appendix 8.1). A draft copy of this report was sent to the Premier and Minister for Health for comment. A partial response was received on 9 May 2005 and a further response on 12 May 2005 – both well after the extended deadline. An analysis of the response from the South Australian Government (reproduced in Appendix 8.4.4) and an overall review of mental health service delivery in South Australia is contained in Part 2.7.4.

6.4.1 STANDARD 1: RIGHTS

The rights of people affected by mental disorders and / or mental health problems are upheld by the MHS.

Under this Standard, a submission indicated concern about:

• the lack of information provided to consumers and their carers;
• the provision of information about rights; and
• the rights of carers.

6.4.1.1 Information not provided

Standard 1.8 states: ‘The MHS provides consumers and their carers with information about available mental health services, mental disorders, mental health problems and available treatments and support services’. According to one NGO service provider this is not occurring. This is of concern on many levels with regards to consent, choice, the right of a person to know about their illness and the treatment plan (and any side-effects), and for carers to be informed regarding what is and will be happening and how they best support the consumer or access support for themselves.

Very limited written information was provided as “standard consumer information” and access to a more detailed outline of the program was only possible because I was allowed to see a copy and I then shared it with the family.

(NGO Service Provider, South Australia, Submission #233)

The lack of provision of ‘standard consumer information’ also implies that this consumer and family were not provided with a written or verbal statement of their rights and responsibilities as required by Standard 1.2 (Consumers and their carers are provided with a written and verbal statement of their rights and responsibilities as soon as possible after entering the MHS).

6.4.1.2 Consumers not informed of their rights

Concern was expressed that some consumers were not being provided with a written and verbal statement of their rights and responsibilities as soon as possible after entering the Mental Health Service (Standard 1.2) in a manner that was understandable (Standard 1.3). This was alleged to be occurring with both voluntary and involuntary patients.

Rights are not always explained to voluntary or detained patients.

(Consumer, South Australia, Submission #77)

6.4.1.3 The rights of carers

The Carers Association of South Australia raised concerns about the rights of carers and the need to develop a comprehensive policy on the role and function of carers to define their rights. They argued this was important as much of the care for people with mental illness is provided in the community by families and therefore they need to have some of their rights formally recognised:

The Carers’ confusion, stress and tension are exacerbated by failure of the Mental Health system in SA to develop and adopt a comprehensive policy on the role and function of carers in the support of people with a mental illness. This has led to the situation where carers are either ignored by mental health professionals or patronised. At worst, the reaction of the mental health system professionals towards family Carers may be hostile.

(Carers Association of SA, South Australia, Submission #30)

However, it is common for Carers of people with a mental illness to experience a lot of rejection of their caring role, not only from their family member but also from the mental health service system.

(Carers Association of SA, South Australia, Submission #30)

There is a lack of acceptance by the Mental Health System of the Carers legal authority where Enduring Power of Guardianship is held by the Carer. This relates to many of the issues previously highlighted but also relates to:

•  The legal authority needing to be triggered by the incapacity of the consumer and this can be hard to define, assess and / or diagnose.

•  There is no central registration of legal orders such as Enduring Power of Guardianship / Attorney, so therefore the orders are not viewed as valid by professionals.

•  Consumers when unwell can verbally discredit the legal authority held by the Carer, making their legal standing ineffective.

•  Although Carers are mentioned in the Mental Health Legislation it is not elaborated upon and they are therefore not afforded rights within in the Mental Health System despite the fact that of much of the care in the community (in the area of mental health) is provided by families.

(Carers Association of SA, South Australia , Submission #30)

6.4.2 STANDARD 2: SAFETY

The activities and environment of the MHS are safe for consumers, carers, families, staff and the community.

Under this Standard, submissions and presentations indicate concerns about:

• lack of services for children and youth with behaviour problems; and
• requirement for staff to be trained to respond appropriately to aggressive and difficult behaviour.

6.4.2.1 Lack of services for children and youth with behaviour problems

According to the notes for Standard 2.2 ‘safety’ is considered in the broadest terms: physical, social, psychological and cultural dimensions. Specifically, Standard 2.2 states: ‘Treatment and support offered by the MHS ensures that the consumer is protected from abuse and exploitation’. According to reports received from both a carer and a teacher, children and youth with mental health issues and behaviour problems are being expelled and excluded from school due to their aggressive behaviour. This has been a result of an inability to access services to treat and support these children and youth. This also led to safety concerns for family members, teaching staff and other students at school.

His episodes can be quite abusive and destructive. When I try to help him at this time he threatens me and destroys my property… I am in fear of what [X] is going to do next, to me, to my property, and most of all to himself. This pattern has been our life since [X] was in Primary School.

(Carer, Mother, South Australia, Submission #195)

I have staff using the expulsion / suspension guidelines to exclude these kids. I have staff being attacked by kids who are on drugs. Because of a lack of services there’s nothing left but to exclude these kids. Actually they really need care.

(Teacher, South Australia, Murray Bridge Forum #17)

The additional and unfortunate consequence of failure to access services is the potential to destroy relationships and disruption to education and future employment and life potential for these children and youth.

6.4.2.2 Requirement for staff to be trained to respond appropriately to aggressive and difficult behaviour

Concern was also expressed within treatment settings that nurses are insufficiently trained to ‘understand and appropriately and safely respond to aggressive and other difficult behaviours’ (Standard 2.4). This results in unnecessary use of force to control situations and jeopardises both the safety of consumers, staff and other consumers in treatment settings.

As a nurse academic and educator, I am aware that it seems that nurses often adopt or are directed to adopt a zero tolerance to aggression and violence, creating an often adversarial stance with patients and thus increasing the possibility of an aggressive episode. There is evidence of this in the recent report (2004) entitled ‘Aggression and Violence in Health Care’ by the Australian Patient Safety Foundation where patients were confronted by nurses for smoking in the wrong place and due to mismanagement, a nurse was assaulted and the patient punished and placed in seclusion. This is avoidable and unacceptable workplace practice. Patients deserve better care, nurses deserve high quality ongoing education and support to provide them with the skills and knowledge to care for people with difficult behaviours.

(Academic, South Australia, Submission #142)

6.4.3 STANDARD 3: CONSUMER AND CARER PARTICIPATION

Consumers and carers are involved in the planning, implementation and evaluation of the MHS.

Under this Standard, submissions and presentations indicate concerns about:

• the ‘tokenistic’ approach to consumer and carer involvement;
• lack of funding to support consumer and carer participation; and
• youth participation.

6.4.3.1 Tokenistic approach to consumer and carer involvement

An advocate was so convinced and exasperated with her experiences of consumers and carers not having a voice or role in the ‘planning, implementation and evaluation of the MHS’ that she stated:

We’re at no risk of being threatened for speaking out because we’re not being heard at all!

(Advocate, South Australia, Adelaide Forum #15)

This ‘lack of involvement’ and need was also confirmed by a clinician and another advocate at the same forum.

There is a token approach to consumer and carer participation – tokenistic responses. There is no carer and consumer input. No feedback.

(Clinician, South Australia, Adelaide Forum #11)

According to Standard 3.1 and 3.2 policies and procedures are implemented to ‘maximise their roles and involvement’ and ‘the MHS undertakes and supports a range of activities’ that maximise consumer and carer participation.

6.4.3.2 Lack of funding for consumer and carer participation

Related to the lack of meaningful consumer and care participation is the reported lack of funding allocated to support such activities.

There’s a need for a rural consultation in areas like Port Augusta… There’s also a need for consumers, carers etc to be heard and to be supported with funding.

(Advocate, South Australia, Adelaide Forum #15)

I’ve been involved in the Murray Mallee Consumer Advisory Group for 6-7 years. The first 3 years we funded ourselves. At the moment we are providing a wide service. Responsible for providing education, networking. We do all of this on a budget of $4,000 per year from the Murray Mallee Health Service. Our funding hasn’t increased in the last four years.

(Consumer & Advocate, South Australia, Murray Bridge Forum #8)

Consumers and carers continue to be largely denied effective participation in both their personal treatment and in the development of effective service delivery systems.

(Clinician, South Australia, Submission #56)

6.4.3.3 Youth participation

Youth Affairs Council of South Australia (YACSA) emphasised the importance of participation by youth in reform processes to maximise health outcomes for children and young people. Mental health, drug and alcohol abuse and access to services (especially for young people in rural, regional and outer metropolitan areas) were noted as critical issues for consultation with young people:

YACSA welcomes a health reform process with a human rights perspective that identifies children and young people as a priority population group, and a reform process with a focus on community participation, as determined by the Generational Health Review. In general, health services for young people in South Australia are increasingly inclusive with regard to youth participation in service planning and delivery. YACSA notes that this should be encouraged, and that the need remains for youth health advisory mechanisms such as the now defunct Department of Human Services' Youth Views project. Council contends that such an approach is imperative if youth health issues are to be addressed adequately.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

For a number of years, YACSA has recommended that the State Government establish and resource a youth health advisory mechanism to provide advice to the Department of Human Services on policy and strategic issues aimed at maximising health outcomes. With issues of mental health, sexual health, drug and alcohol abuse and access to services (particularly for young people in rural, regional and outer metropolitan South Australia), there is an urgent need to act on the implementation of an appropriate advisory structure to the Minister for Health. Given the Generational Health Review emphasis on regionalisation and community participation, YACSA recommends that the Department of Human Services establish a number of regional Youth Health Advisory Committees in key, strategic locations as determined through the process of decentralising the existing health system. YACSA envisages that the Committees would comprise relevant departmental officers and non-government stakeholders in the youth, community and mental health sectors, as well as representation from young people / consumers. YACSA further recommends that the structure of the Committees be based on the previously successful Youth Views young consumer participation model, with executive support to be provided by existing staff.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

6.4.4 STANDARD 4: PROMOTING COMMUNITY ACCEPTANCE

The MHS promotes community acceptance and the reduction of stigma for people affected by mental disorders and / or mental health problems.

Under this Standard, submissions and presentations indicate concerns about:

• the high levels of stigma and discrimination still being experienced by people with mental illness;
• feelings of isolation – rejection by family members and the community;
• discrimination directed towards children of parents with mental illness;
• non-acceptance by mental health workers;
• discrimination in employment; and
• stigma and stereotypes perpetuated by the media.

Members of the wider community often have inaccurate perceptions of mental illness, leading to further isolation and exclusion of those who are unwell.

(Health and Community Services Network, Murray Mallee Strategic Task Force, South Australia, Submission #115)

6.4.4.1 High levels of stigma and discrimination

Carers and advocates continue to express concerns about the high level of stigma and ostracism still being experienced by people with mental illness. This would indicate that campaigns and activities to address community acceptance and reduce stigma (Standard 4.1) to date have not been able to turn community attitudes around. As described below, discrimination and lack of community acceptance are key barriers to people with mental illness (and their family members) being able to participate socially, economically and politically in society. Social isolation is often the result.

There is a great stigma being attached to having a mental illness.

(Advocate, South Australia, Adelaide Forum #15)

In the early years of my mental illness I felt self conscious and didn’t like to bother my doctor over my mental illness. As time went by I became used to seeing my GP every two weeks without feeling bad about taking up his time on a regular basis. Feeling this way is caused by stigma, devaluing myself and my frustration at taking years to get well.

(Consumer, South Australia, Submission #77)

I have 2 sons who have schizophrenia. [X] (eldest son) had a bad breakdown so we decided we would move to a small community to give him a better chance at life but the stigma here was very bad – when our sons went to the pub for a drink the locals would move away from them.

(Carer, South Australia, Murray Bridge Forum #10)

My elder son and myself are [X]’s sole supports.

(Carer, Mother, South Australia, Submission #279)

Finally I have lost some friends because they could not accept or cope with my mental illness. My new friends have their own mental illness and we meet to socialise and support each other but not in an integrated community way.

(Consumer, South Australia, Submission #77)

In the absence of services to educate the community and services to support integration, family members have reported going to great lengths to assist in this process.

On one occasion when my son was ill he frightened some people in the town and when he was in hospital I put an advertisement in the paper to thank the police for their help but also to try to educate the community that he had received treatment and was not a threat to them. It didn’t really help.

(Carer, South Australia, Murray Bridge Forum #10)

I have a family member with a mental illness, and I have encouraged my family member to become involved in the community.

(Carer, Family Member, South Australia, Adelaide Forum #2)

6.4.4.2 Feelings of isolation – rejection by family members and the community

Concern was expressed that stigma and lack of understanding still shape community behaviour and result in the exclusion of people with mental illness in social and workplace settings, and often this behaviour extends to close family members and intimate partners, resulting in relationship breakdown. Standard 4.1 states: ‘The MHS works collaboratively with the defined community to initiate and participate in a range of activities designed to promote acceptance of people with mental disorders and / or mental health problems by reducing stigma in the community.’ As the following quotes indicate, the need for activities to promote community acceptance not only for the community but for family members as well is critical:

Stigma within the family has been great, as well as in the community. These people need more supported housing and employment options, desperately. There also needs to be more community awareness about mental illness.

(Family member, South Australia, Submission #6)

6.4.4.3 Discrimination directed towards children of parents with mental illness

The extent of the problem with regards to the high level of stigma in South Australia is evidenced by reports of discrimination experienced by children of parents with mental illness:

There is still a stigma in the Mallee against people with a mental illness (especially if they were not born and bred in the Mallee). This also leads to discrimination against the children of parents with a mental illness.

(Health and Community Services Network, Murray Mallee Strategic Task Force, South Australia, Submission #115)

Because my kids don’t get any support, in fact they get teased about having a father who is mentally ill, they then come home and take it out on me; tell me I’m nuts or I’m a loony.

(Consumer, South Australia, Murray Bridge Forum #1)

6.4.4.4 Non-Acceptance by mental health workers

Many consumers and carers also expressed concerns about the lack of acceptance and understanding and what they labelled as discriminatory attitudes shown by some service providers. This is of particular concern given that consumers must come directly into contact with mental health service providers and their views impact directly upon them and their carers:

South Australia has a mental health care system of quick fixes and is staff orientated. In my opinion, mental health services staff are overwhelmingly repulsed by the symptoms of mental illness. What is required is change to a consumer-oriented system that recognises ‘fine minds’.

(Consumer, South Australia, Submission #41)

6.4.4.5 Discrimination in employment

Employment and a supportive workplace are seen as key factors in preventing the rapid escalation of mental illness and as being essential in the process of rehabilitation and reintegration into society after a period of mental illness. Standard 4.2 states: ‘The MHS provides understandable information to mainstream workers and the defined community about mental disorders and mental health problems’. However, acceptance and understanding of mental illness seem to be lacking in the workplace and discrimination and high levels of stigma are still prevalent in workplace settings:

Employment potential is nil as no one would employ someone who has had a mental illness and been out of the workforce for any length of time such as my ten years so far. The stigma and bias against mentally ill people puts paid to reemployment.

(Consumer, South Australia, Submission #77)

In respect to employment a person can have extended sick leave for a physical ailment or condition but if mentally ill it may be impossible to return to work. A period of mental illness is not looked on favourably by an employer. Applying for work knowing one has been mentally ill for ten years as is the case for me is exceedingly difficult because of stigma. It is assumed I cannot cope with daily life but if I had a broken leg or a bad heart no one would judge me in relation to coping with daily life let alone work. I don’t have the right of a job or the right to suffer an illness without bias. Although I do voluntary work at school five days a week for a half hour per day I can’t work but if it was possible I might be able to work part time in the future.

(Consumer, South Australia, Submission #77)

6.4.4.6 Stigma and stereotypes perpetuated by the media

Concerns were also raised that any activities by the MHS to reduce stigma in the community must also address education of media personnel to modify their portrayal of people with mental illness and comparative references.

In my opinion there is considerable stigma attached to being mentally ill. The media often reports on certain mentally ill people as being dangerous and frightening. My mentally ill friends and myself are nether dangerous or frightening. Our society expects that people get physically sick but if a person becomes mentally ill for a time they are told unkindly to pull their self together. No understanding is entered into.

(Consumer, South Australia, Submission #77)

6.4.5 STANDARD 5: PRIVACY AND CONFIDENTIALITY

The MHS ensures the privacy and confidentiality of consumers and carers.

Under this Standard, submissions indicated concern about policies and procedures to protect privacy and confidentiality.

6.4.5.1 Staff applying privacy and confidentiality rules without authority or ignore or do not request permission from consumer to share information or involve carers

The Carers Association of South Australia expressed concern that misunderstanding or rigid application of policies and procedures to protect the confidentiality and privacy of consumers is impeding communication between consumers, carers and clinicians in the provision of treatment and the sharing of vital information. These concerns indicate that policies and procedures related to privacy and confidentiality may not be made available to consumers and carers in an understandable language and format (Standard 5.2) and that the mental health system is not encouraging and providing opportunities for consumers to involve others in their care (Standard 5.3). The following quote indicates the level of frustration and despair experienced by carers:

Doctrines of confidentiality and privacy of adult patient information are often interpreted by some professionals and adhered to so strongly within that Carers are intentionally not provided with information about medication, treatment and progress. Also, they are frequently denied linkages with those treating the consumer, even though Carers are expected to support and manage the care of the consumer in the community. The reality is that care provided in the community by family members frequently occurs without recognition from the mental health system, the professionals, or the general health care and primary health care sectors.

(Carers Association of SA, South Australia, Submission #30)

While the following report from one carer suggests that the incident occurred some time ago, it nonetheless demonstrates the negative consequences to relationships that can follow from the total exclusion of carers in the treatment process and failure of carers to be informed (Standard 5.2) and clinicians to understand and apply appropriate privacy and confidentiality policies and procedures:

I was married to a paranoid schizophrenic and did not know… No Dr. would tell me – ethics, the result was, this “man” totally destroyed my life, and there was not a thing I could do about that legally… I am still trying to “pick myself up off the floor”, but sadly never will.

(Carer, Wife, South Australia, Submission #148)

6.4.6 STANDARD 6: PREVENTION AND MENTAL HEALTH PROMOTION

The MHS works with the defined community in prevention, early detection, early intervention and mental health promotion.

Under this Standard, submissions and presentations indicate concerns about:

• the lack of focus on prevention in mental health services;
• lack of services for children and youth; and
• ack of rehabilitation programs and recovery services.

6.4.6.1 Prevention not a focus of mental health services

The Health and Community Services Network (Murray Mallee Strategic Task Force) made particular mention of the lack of a preventive focus in mental health services in South Australia.

The mental health system still has its focus on acute care at the expense of preventative work and community supports. South Australia spends a lower proportion of its mental health budget on community based supports than other mainland states.

(Health and Community Services Network, Murray Mallee Strategic Task Force, South Australia, Submission #115)

Indeed, Standard 6.1 states: ‘The MHS has policy, resources and plans that support mental health promotion, prevention of mental disorders and mental health problems, early detection and intervention.’ Evidence presented in other sections of this Report support the above claim of a lack of community services to intervene early and therefore avert the need for acute care. This focus on the provision of acute care and hospital based services, rather than community based care, is also contradictory to Standard 6.6 ‘Treatment and support offered by the MHS occur in a community setting in preference to an institutional setting unless there is justifiable reason consistent with the best outcome for the consumer.’

Another aspect of prevention is to assist consumers to identify ‘early warning signs of relapse and appropriate action’ (Standard 6.7). Evidence was also presented that sufficient information with regards to prevention and mental health problems is not being provided at either a community, individual or carer level.

There is a general lack of awareness and information about mental illness, so that those affected and their friends and family members may not realise that they are becoming unwell.

(Health and Community Services Network, Murray Mallee Strategic Task Force, South Australia, Submission #115)

6.4.6.2 Lack of services to provide early intervention for youth is a critical problem

…others who unfortunately enter the system from “Boys Homes” because of existing childhood problems seemed trapped in a vicious punishment cycle. They need desperate help for their symptoms, not continual punishment. This ‘lockup the too hard basket’ attitude makes it almost impossible for people like [X] who have had an abusive childhood combined with mental problems to survive. This is no way to help a person with psychiatric problems who is suicidal. The system seems to be continuing the abuse his father started. He never had any time with out abuse to get his life together.

(Carer, Mother, South Australia, Submission #195)

The availability of services to provide treatment for children and youth with mental illness or mental health problems is critical in terms of averting serious life repercussions. Standards 6.4 (‘The MHS has capacity to identify and appropriately respond to the most vulnerable consumers…’) and Standard 6.5 (‘ .. as early as possible’) are clearly not being met according to the concerns expressed in this Report. The concerns expressed here follow concerns previously expressed under Standard 2 (Safety) with reference to protecting the social and psychological wellbeing of children and youth.

We just don’t have the resources to support these kids so the schools call the police. Yes we have other avenues, other services but how do we access these – the waiting lists are sometimes 18 months. These kids do not complete their education and they end up in a life of trouble – a horrendous situation – we have the mandate to keep the schools safe – but it’s too hard.

(Teacher, South Australia, Murray Bridge Forum #17)

This pattern has been our life since [X] was in Primary School. The cycle has to be broken, as we all deserve a better quality of life…

(Carer, Mother, South Australia, Submission #195)

6.4.6.3 Lack of rehabilitation programs and recovery services

Rehabilitation programs are acknowledged as a critical step in the reintegration process back into full life after a period of illness and the prevention of relapse for many people with mental illness. Such programs would include living skills programs, respite and social programs. Standard 6.8 states: ‘The MHS ensures that the consumer has access to rehabilitation programs which aim to minimise psychiatric disability and prevent relapse’. Concern was expressed by one consumer that he has been unable to access any rehabilitation programs in his area:

Sadly my mental illness has led to me being ill from 1994 to 2004. I am still ill but despite no available rehabilitation program of any sort I try to do voluntary work and do things at home when I can.

(Consumer, South Australia, Submission #77)

Information about mental illness for patients and their families is not forth coming and there is not therapy or rehabilitation in the country such as Murray Bridge in SA. I have spent ten years 1994-2004 doing my own rehabilitation. I was a social worker prior to becoming very mentally ill.

(Consumer, South Australia, Submission #77)

6.4.7 STANDARD 7: CULTURAL AWARENESS

The MHS delivers non-discriminatory treatment and support which are sensitive to the social and cultural values of the consumer and the consumer’s family and community.

Under this Standard, submissions and presentations indicate concerns about:

• the lack of culturally appropriate practices for Indigenous people;
• lack of culturally appropriate practices for consumers from a non-English speaking background; and
• the need for culturally appropriate mental health programs for newly arrived young people

6.4.7.1 Lack of culturally appropriate practices for Indigenous people

Evidence was presented which suggests that mental health services have not been planned and delivered in a manner which ‘considers the needs and unique factors of social and cultural groups represented in the defined community and involves these groups in the planning and implementation of services’ (Standard 7.2).

I’m an Aboriginal Mental Health Worker for the region. Gender issues are a real problem. I’ve got a case-load of roughly 20, plus their families and then I get new referrals, though many indigenous people do not access services anyway. There’s a gender problem too which makes it even harder because some Aboriginal males can not approach female psychiatrists and females won’t approach male psychiatrists.

(Clinician, South Australia, Murray Bridge Forum #4)

When indigenous people become unwell they are all put in baskets, they either have a mental illness or a drug and alcohol problem. There’s no holistic care. There have been 20 close deaths in my family.

(Anonymous, South Australia, Murray Bridge Forum #15)

However, the Medical Specialists Outreach Assistance Program, funded by the Federal Government, has improved Indigenous services to South Australia's rural and remote communities by providing culturally sensitive mental health services to Aboriginal people in their own communities.

…significant progress that has been made in Sth Aust during the last 2 years in the development of outreach psychiatric services to remote communities in SA under the Medical Specialists Outreach Assistance Program funded by the Federal Govt. They describe the efforts of a group of Adelaide based psychiatrists to provide culturally sensitive mental health services to Aboriginal people in their own communities. The practice model used is that of a Consultation / Liaison model which emphasises the support and upskilling of the local mental health workers. This is a new application of the C-L model. It appears to be reasonably successful in delivering sustainable services to rural and especially remote areas.

(Clinician, South Australia, Submission #274)

6.4.7.2 Lack of culturally appropriate practices for consumers from a non-English speaking background (NESB)

Comments were received which suggests that mental health services have not been planned and delivered in a manner which ‘considers the needs and unique factors of social and cultural groups represented in the defined community and involves these groups in the planning and implementation of services’ (Standard 7.2). Concern was expressed that even though culturally appropriate practices could be enhanced by a variety of strategies, for example, redesigning job descriptions or employing staff from a variety of backgrounds, organisational support and sufficient resources are not available to enable this to occur. Also, concern was expressed that where strategies had been devised by staff to improve service delivery to consumers from a NESB, proposals have been allegedly ignored:

A recent such example comes from a clinician concerned with access and equity and appropriateness of assessment and treatment methods for persons of diverse linguistic and cultural backgrounds. When past reform initiatives encouraged staff to critically assess their practice and methods with respect to these issues, this, and other clinicians developed some proposals which responded to the National Standards for Mental Health Services, as well as policies and regulations within the State Public Service and specific health services / regions. These proposals were met with contempt, not deserving of even the acknowledgement of being received, in spite of the promise by the current Minister for Health, when in opposition, that, if elected, she would give it serious consideration. All the way down the hierarchy, resistance to suggestions from the "battlefront" were shoved aside and ignored. The response of management has consistently been to stonewall such proposals, to never respond to them, never to reject them on the basis of rational/objective criticism, but to simply ignore them, in spite of these proposals being re-submitted, adjusted to new circumstances and knowledge etc. Over more than 5 years this particular clinician submitted proposals that were essentially costless, but required a minimal reallocation of existing resources, while providing an important qualitative improvement to access and equity and appropriate assessment and treatment approaches.

(Clinician, South Australia, Submission #56)

The marginalisation / denigration takes different forms. One has been the withholding of an appropriate and relevant Job Description for many years, up to the present time, in spite of regular requests from the concerned clinician, many meetings and vague promises. Another form has been the constant verbal character assassinations of the clinician as racist because of [his / her] focus on non-Anglophone immigrants, to [his / her] face and to others, or on the phone. The team leader felt so confident of being at least passively supported by [his / her] superiors that [he / she] eventually lodged a memo to the Service Director accusing the clinician of being racist in [his / her] patient / client selection. Higher management did not respond to this memo, other than making the verbal comment to the clinician that "well there are people who think you should see more English speakers", ignoring the fact that this clinician was the only practicing multilingual staff member of [his / her] service of about 50 staff, and that no other staff member was being asked to see more non-Anglophone patients / clients, in a region where more than one third of the total population is of non-English speaking background, and the rate of referral of persons of non-English speaking backgrounds is in excess of 40% on average over time. This clinician has sought to have the issue of these accusations addressed, but so far unsuccessfully. This is only one example, but it clearly illustrates an organisational culture paralysed by lack of forward looking principles, lack of any ideas of how to put into practice the existing principles of mental health reform contained in the National Standards for Mental Health Services and the mental health reform agenda in general, and an organisation which resorts to tactics of petty repression, bullying etc to maintain the status quo of bureaucratic politics, in a textbook case of sociological / organisational dysfunction.

(Clinician, South Australia, Submission #56)

6.4.7.3 The need for culturally appropriate mental health programs for newly arrived young people

The Youth Affairs Council of South Australia (YACSA) raised concerns about the need for culturally appropriate mental health programs for newly arrived young people:

YACSA's report Out of the Mist: Young People, Emotional Well Being and Life Choices, prepared in conjunction with the Migrant Health Service and the Adelaide Central Community Health Service, contains several recommendations for increasing the effectiveness of mental health services provided to newly-arrived young people. Given the State Government's commitment to culturally appropriate mental health programs, and its pledge through the Platform for Government to ensure that CLDB [Culturally and Linguistically Diverse Background] young people, particularly those who are newly arrived, have access to the services they need. YACSA proposes that a centralised peer support training program be established. This could possibly be in collaboration with TAFE and Multicultural Youth South Australia, to provide trained youth peer support workers from relevant communities to work with community agencies to support newly-arrived young people, from a mental health perspective. Such a project might be modelled on the Cornerstone project currently being run by the Adelaide Central Mission and the Migrant Health Service. Peer support workers would be appropriately trained to work with the relevant issues and would receive ongoing support in their roles.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

6.4.8 STANDARD 8: INTEGRATION

6.4.8.1 Service integration

The MHS is integrated and coordinated to provide a balanced mix of services which ensure continuity of care for the consumer.

People could be placed in the hospital without any mental health workers.

(Clinician, South Australia, Murray Bridge Forum #14)

Under this Standard, submissions and presentations indicate concerns about:

• problems with continuity between adolescent and adult mental health services;
• the link between mental health services and general practitioners; and
• integration with NGO services.

6.4.8.1.1 Problems with continuity between adolescent and adult mental health services

There is a lack of continuity between Child and Adolescent Mental Health Service (CAMHS) and adult mental health services.

(Health and Community Services Network, Murray Mallee Strategic Task Force, South Australia, Submission #115)

As mentioned previously, not only were concerns raised at the scarcity of services for children and youth, but concerns have also been raised with regards to the continuity of care between adolescent and adult mental health services. Standard 8.1.5 states: ‘The MHS has documented policies and procedures which are used to promote continuity of care across programs, sites, other services and lifespan.’

Young people 16-17 come and see us but we do some transitioning to the adult mental health service also. There is a period when there’s nothing for young people during this transition.

(Clinician, South Australia, Murray Bridge Forum #14)

6.4.8.1.2 Link between mental health services and general practitioners

Included in Standard 8.1.5 are arrangements for shared care with general practitioners. Varied reports were received with regards to successful shared care arrangements.

GPs sometimes don’t listen and a client didn’t get admitted because the GP wouldn’t support admissions.

(NGO Worker, South Australia, Adelaide Forum #24)

There are some advantages to working in this type of area. There’s a community of professionals with the local GP’s. I can phone the local GP’s for a social admission.

(Clinician, South Australia, Murray Bridge Forum #14)

Some GPs are concerned about taking action (when a person is in need of being collected by the police it is necessary for a doctor to approve an involuntary admission).

(Advocate, South Australia, Adelaide Forum #15)

Notwithstanding the excellent but limited TELEMED and TRIAGE services from Glenside Hospital Campus local GP’s can receive consultation with distant psychiatrists to help them manage their local mentally ill patients. Sadly such a service doesn’t serve patient’s family by enabling them to understand their family member’s mental illness; to see and keep in touch with their loved one because of the distance from home to hospital.

(Consumer, South Australia, Submission #77)

6.4.8.1.3 Problems with integration with NGO services

One NGO service provider expressed concern about not being able to work together with other mental health service providers in a coordinated and integrated manner as stated in Standard 8.1.5.

At that further meeting with the Program Director and other family therapist, and after trying to gain clarification on how we could collaborate, I was clearly told that this could not occur and we could only work in “parallel.” I was not allowed to discuss my approach with the young person’s regular nursing staff and how their work may contribute to the therapeutic process. Although I appreciated that there may be some sensitivities and caution with collaborating with someone outside of their hospital, like myself, there was no flexibility on this matter – something that stands apart from recommended good practice in interagency or private/public sector collaboration.

(NGO Service Provider, South Australia, Submission #233)

6.4.8.2 Integration within the Health System

The MHS develops and maintains links with other health service providers at local, state and national levels to ensure specialised coordinated care and promote community integration for people with mental disorders and / or mental health problems.

Under this Standard, a presentation indicated concern about:

• the lack of access to health services to meet the physical health needs of people with mental illness.

6.4.8.2.1 Lack of access to services to meet physical health needs

One police officer expressed concern about his / her repeated observation that people with mental illness appear to be having difficulty accessing health services to meet their physical health needs.

There are good things happening but my client groups are the difficult ones. Since the closure of the institutions there has been a large influx of people into this community. But these people need access to other health services for their physical and mental health needs – they often get sent on buses and taxis to Adelaide for care.

(Police Officer, South Australia, Murray Bridge Forum #16)

Mentally ill people can suffer other medical problems such as;

•  arthritis (lithium possibly leaching calcium)

•  sleep apnea (may have triggered epilepsy

•  underactive thyroid (lithium for mood side effect)

•  weight problems (zyprexa major tranquiliser)

•  epilepsy (imbalance in brain biochemistry)

These conditions can require referral to other specialists and in my case only some visit Murray Bridge but others are seen in Adelaide .

(Consumer, South Australia , Submission #77)

6.4.8.3 Integration with other sectors

The MHS develops and maintains links with other sectors at local, state and national levels to ensure specialised coordinated care and promote community integration for people with mental disorders and/or mental health problems.

Under this Standard, submissions and presentations indicate concerns about integrated service with regards to:

• housing and accommodation;
• home and community care;
• police;
• education;
• youth;
• employment and support from Centrelink;
• youth employment;
• transport;
• carer allowance;
• cost of medication;
• wards of the state;
• health in rural and remote areas; and
• the criminal justice system.

Integration with these, and other sectors, is vital in the whole-of-government approach required to realise the rights of people with mental illness.

The necessity of a whole-of-government approach to specifically care for children who have become wards of the state was also specifically raised through this consultation process.

6.4.8.3.1 Housing

There’s a real revolving door syndrome – people get admitted, they get treatment and then they get discharged but because there’s no supported accommodation for them they keep coming back into the hospital.

(Clinician, South Australia, Murray Bridge Forum #5)c

Lack of available housing and accommodation options for people with mental illness was repeatedly raised as a critical gap in the process of integrating people with mental illness in the community and improved mental health (see Standard 11.4.B Supported Accommodation). The lack of available housing and accommodation options and the process of deinstitutionalisation and consequent lack of increased community services has also seen an increase in the proportion of people who are homeless who have a mental illness. The housing and accommodation needs of young people were highlighted as major areas of concern by Youth Affairs Council of South Australia.

Housing availability is critical here. Once we get people with a mental illness in our service there’s nowhere else for them to go and then we are so stretched we can’t respond to the needs of our other clients.

(Accommodation Service Provider, South Australia, Adelaide Forum #4)

Disability supported housing is the only option available, but as there is no interaction with mental health services people with mental disability miss out. There are some disability support mechanisms but they’re not funded to support those with a psychiatric disability. We can get them in if they have a dual disability. HACC [Health and Community Care] funding means we can not help people with psychiatric disability only.

(NGO Service Provider, South Australia, Murray Bridge Forum #6)

In his father’s opinion neither Governments nor Departments or Courts understand the impact of [X]’s continued homelessness upon his current situation.

(Anonymous, South Australia, Submission #183)

Changes to the Commonwealth State Housing Agreement over recent years have in turn necessitated changes in the provision of public housing in South Australia. YACSA contends that the housing needs of young South Australians must take a priority for the State Government through the South Australian Housing Trust. Public housing plays a fundamental role in the reduction of housing-related poverty and broader social and economic inequalities, offering young people non-discriminatory, affordable housing with security of tenure. In consultation regarding the discussion paper for the upcoming Youth Action Plan, young people noted that it is increasingly difficult to access public housing, and that even if a young person is in need, they are often not in 'enough need' to warrant priority housing. As one young participant noted, "You need to be having a baby to get a house."

(Youth Affairs Council of South Australia, South Australia, Submission #38)

YACSA strongly commends the State Government on its initiation of a ten-year State Housing Plan for South Australia. Council reiterates the Minister for Housing's assertion that young people should be a focus of any initiative that aims to improve housing services for South Australians. In light of this, YACSA recommends that a Youth Housing Strategy comprise a core component of the State Housing Plan, to be developed in conjunction with young people and stakeholders in the youth sector. A Strategy would need to take into consider the particular housing needs of a variety of youth populations, including Indigenous young people, young people leaving care, young people with disabilities including mental health issues, newly arrived young people, etc. Also, while the Plan is statewide in scope, YACSA notes that housing needs vary around South Australia, and needs are not homogenous across all metropolitan areas or all regional areas, a feature that needs to be considered in every stage of the Plan. Features of the Youth Housing Strategy should include but not be limited to:

A commitment to working across Government to improve housing outcomes for young people. The strategy should draw together the Department of Human Services (including the Office for Youth, the South Australian Housing Trust, the Aboriginal Housing Authority, the South Australian Community Housing Authority and Family and Youth Services), the Department of Education and Children's Services, the Department of Further Education, Employment, Science and Technology, the Office of Consumer and Business Affairs and relevant others to establish a service and support framework cognizant of the vital role stable, appropriate housing plays in young people's ability to participate in education, training and employment and maintain a healthy lifestyle.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

6.4.8.3.2 Home and Community Care (HACC)

Mental illness isn’t recognised as a disability by HACC services.

(Anonymous, South Australia, Adelaide Forum #10)

The ineligibility of people with mental illness to qualify for HACC services was described by one consumer as an example of direct discrimination. An inability to access HACC services makes it difficult if not impossible for some people with mental illness to continue to choose to live independently.

People with a mental illness are discriminated against. People with other health problems who have been in hospital will get Domestic Care but not so for people with a mental illness – surely they should get the same sort of help.

(Consumer, South Australia, Murray Bridge Forum #7)

In the HACC guidelines there’s no acknowledgement of mental illness.

(Social Worker, South Australia, Adelaide Forum #20)

We get our funding through HACC and HACC doesn’t include psychiatric disability as a disability. It’s very hard to link in with the mental health side of it because there’s a very limited number of people to work with and the funding is limited. Dual disability is the biggest problem because it’s very difficult to network when everyone is so stressed and stretched.

(NGO Service Provider, South Australia, Murray Bridge Forum #6)

6.4.8.3.3 Police

One police officer raised concerns that collaboration was not occurring to the mutual benefit of all professionals involved in the provision of services to people with mental illness. This feeling of frustration stemmed from a desire to work collaboratively with other professionals to achieve the best possible outcome for consumers given the limited resources and overwhelming demand. Standard 8.3.2 states: ‘The MHS supports staff, consumers and carers in their involvement with other agencies wherever possible and appropriate’ and Standard 8.3.3 states ‘The MHS has formal processes to develop intersectoral links and collaboration.’

We are very frustrated at the coal face. I’ve charged 1,000’s of people. I know when someone is mentally ill. As far as I’m concerned there’s no collaboration between professionals in this community. The doctors do not listen to what we say, we don’t get any acknowledgement. The doctors won’t talk to the nurses or the teachers either.

(Police Officer, South Australia, Murray Bridge Forum #16)

6.4.8.3.4 Education

Similarly, Standards 8.3.2 and 8.3.3 apply to the education sector, including schools, TAFE and universities. Links with the education sector to assist with early identification and early intervention are critical in any set of strategies targeted at prevention. Many presentations were made at forums expressing concern at the inability of schools and TAFEs to identify and support children and adolescents with mental illness or mental health problems. As a link with strategies to reduce youth suicide, this area of service delivery and need for integration is vital.

Our core business is education – we identify children with intellectual disability but not psychiatric disability. We are not funded to support these kids. We can provide inclusive resources but we can’t really do it properly. Generally they are just piece-meal packages. I have staff using the expulsion / suspension guidelines to exclude these kids… Because of a lack of services there’s nothing left but to exclude these kids. Actually they really need care.

(Teacher, South Australia, Murray Bridge Forum #17)

There’s only 1 FTE [Full-time Equivalent] Disability Coordination Officer for the whole state. We also cover learning difficulties and mental health issues. One of our jobs is to help these kids to get into classes. 1 of our TAFE teachers has 90% of her class with a mental illness.

(Anonymous, South Australia, Adelaide Forum #23)

My position is funded by the Federal Government. I am employed at a 0.5 allocation but my position covers 75% of South Australia.

(Disability Coordinator, South Australia, Adelaide Forum #17)

Alternative education programs have been increasingly recognised by the State Government, schools and the community as an effective way to cater to the needs of young people ‘at risk’, particularly those excluded or otherwise disconnected from mainstream education. The youth sector has this year begun to report that some young people have been disadvantaged and disengaged as a result of the raised minimum school leaving age, and for this group of young people appropriate alternative education options are imperative. Such alternative education programs are frequently delivered by youth workers, and allow young people to learn at their own pace in supported environments where their educational and personal support needs are met.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

Teachers, students and workers in the public school system report that young people's out-of-school concerns such as mental health and child protection issues are having a broadly negative impact on students' educational outcomes. Further, student populations are diversifying, particularly with an increase of newly-arrived and refugee students who are requiring extra support. Consultation by the Social Inclusion Unit with young people earlier this year regarding school retention issues uncovered a strong recommendation from young people that youth workers be employed in public schools to provide direct support and advocacy to students. The consultation report notes that "young people consulted indicated that they would like to see youth workers in schools. They considered that youth workers were:

•  Impartial about student difficulties

•  Knowledgeable about services

•  Good at creating positive connections with young people

•  Able to liaise between students, teachers, parents,

•  Centrelink, and other relevant parties

•  Able to deliver world and life related topics and to speak engagingly about issues such as disability, discrimination and mental health."

(Youth Affairs Council of South Australia , South Australia , Submission #38)

6.4.8.3.5 Whole-of-government approach for youth

The Youth Affairs Council of South Australia expressed concern about the capacity of services to work with youth with high and complex needs. Coordinated services are seen as essential from an early intervention perspective to halt spiralling negative life consequences which result in homelessness, suicide, entry into the criminal justice system or separation from the family. The need for integration with drug and alcohol initiatives was also seen as critical:

There is a consensus across human service agencies working with homeless young people with high and complex needs that the capacity of agencies to retain and work constructively with these clients needs to be developed. There is also a consensus that there is a need for a residential service that can manage and support these young people in extreme circumstances, as an alternative to hospitalisation or worse.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

The highest risk factors to young peoples' health are related to tobacco and alcohol use. YACSA's Policy Platform acknowledges that there are connections between addictive drug use (including alcohol) and wider issues such as suicide, unemployment, homelessness and social alienation. Other interrelated issues include links with poverty, educational outcomes, and living in outer metropolitan, regional, rural and remote areas… Young people's health and the problems they experience are diverse and far-reaching. Inequity, and related issues such as poverty, lack of education, housing and access to basic health services, are broad factors that contribute to the health concerns that many young people face.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

6.4.8.3.6 Employment and support from Centrelink

Access to welfare, the supported wage and finding suitable employment are all critical components in the process of social inclusion and living a meaningful life with dignity in the community. However, many concerns were raised regarding difficulties with the current welfare and employment systems and Centrelink. One example of a successful program, funded by the Federal Government, was described.

I just recently obtained a job cleaning houses. The work became very difficult and I could no longer do it. I was given the option of going off the pension because I was earning too much. The problem was if I then could no longer work I’d have no pension either. Luckily I didn’t go off the pension because I couldn’t keep working.

(Consumer, South Australia, Murray Bridge Forum #12)

I worked as a Job Network case worker of 80 people at Centrelink in Adelaide. 60% of the people I saw had a mental illness but were not on the Disability Pension as nobody would do the paper work to get them on Disability Support Pension. There’s no continuity of process and Centrlink’s sole purpose is to mask employment jobless rather than help them.

(Anonymous, South Australia, Murray Bridge Forum #13)

We need more opportunities for people with psychiatric disabilities and need to restructure the supported wage system. The system doesn’t take into account the episodic nature of mental illness so currently the appraisal system is unfair.

(NGO Service Provider, South Australia, Murray Bridge Forum #11)

We have supportive people here in Centrelink but they are also very under resourced and so the system only benefits people who the can act on their own behalf, not those who are most disabled.

(NGO Service Provider, South Australia, Murray Bridge Forum #11)

It’s really hard to meet your mutual obligations on the disability support pension. I know someone who is trying (for the third time) to apply for the disability support pension. The questions regarding physical disability are focused and straightforward but not for psychiatric disability. Some people are too unwell to meet their mutual obligations.

(NGO Service Provider, South Australia, Murray Bridge Forum #11)

One positive program, funded by the Federal Government, indicated the positive outcomes that be achieved for a particularly vulnerable group when integration works successfully. The rights to social and economic participation and living a life with dignity are greatly enhanced by initiatives such as this.

My program is federally funded and has been running for three years. It’s aimed at supporting those people with a mental illness & acquired brain injury in the indigenous community – it’s a pilot project. After 2 years we had 12 people in employment.

(NGO Service Provider, South Australia, Murray Bridge Forum #11)

6.4.8.3.7 Employment for young people with mental illness or mental health problems

In addition to the general employment concerns raised above, the Youth Affairs Council of South Australia highlighted that specific strategies and initiatives need to be developed to address the issue of barriers to employment for young people with mental illness or mental health problems:

The social cost of unemployment is well-documented; youth unemployment has enormous repercussions for other aspects of young people’s lives and decreases their general social health and wellbeing. Four years ago, the report focusing on metropolitan Adelaide entitled Surviving Unemployment: Health Consequences of Youth Unemployment, noted that "labour market programs for young people focus almost exclusively on job skills targeted to meet the needs of employers whilst the health system has primarily focused on acute symptoms such as youth suicide or depression without tackling their structural determinants. The need for integrated multi-disciplinary approaches to tackle the adverse affects of youth unemployment has never been greater." Such a finding is also consistent with the primary health care approach underpinning the Generational Health Review.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

6.4.8.3.8 Transport

Another related but indirect problem with regard to access to services is transport. This concern was raised at one forum indicating that for many consumers, for a myriad of reasons, reliance on public transport and location of services is critical. Collaboration with local transport providers may also be an essential link to be made to enable access to services without discrimination for all consumers.

Lack of transport impacts considerably on access to services.

(Community Health Service worker, South Australia, Murray Bridge Forum #9)

6.4.8.3.9 Wards of the State – need for a whole-of-government approach

Years of neglect and self abuse have taken their affect. The failures of his parents, the across the board systemic failure of governments, departments and services set up to help, the failure of individuals in positions of authority and support, all form part of the complications that go together to make ‘X’s future existence problematical in the extreme.

(Anonymous, South Australia, Submission #183)

One submission highlighted the need for the Government to adequately care, through a whole-of-government approach, for those children and adolescents placed in the State’s care. This anonymous submission claimed that gaps in multiple areas resulted in the deteriorating mental health of one consumer, resulting in serious life consequences.

But whereas for the most part, parents and families don’t have the knowledge and resources to take determinative action governments do. Failure to honour the trust which is given it to assist a child in need is a failure of government to maintain the rule of law by which we all in security co-exist.

(Anonymous, South Australia, Submission #183)

With the attention that has now been given in South Australia to inmates of hospitals for the mentally ill and the procedures in place to process them, it is hoped that greater attention will be given to the ‘duty of care’ responsibilities place upon governments in regard to those given or taken into their care.

(Anonymous, South Australia, Submission #183)

6.4.8.3.10 Carer allowance

With limited access to mental health services, supported accommodation and access to early intervention treatment and support, the burden on families and carers from providing long-term and crisis support is immense. This often impacts on the financial income of the family due to a reduced ability of carers to work. The shifting of care by governments to carers fails to recognise that carers are providing a significant cost-free service that is not being shouldered by the community. Concern was raised with regard to the financial hardship experienced by carers due to the lack of services in the community to provide appropriate treatment and support to people with mental illness and / or mental health problems:

CENTRELINK CARER PAYMENT - The Carer allowance my wife receives for looking after me works out at 70 cents an hour because income [sic] from superannuation and shows how little carers receive. When compared to the average wage Centrelink payments are considerably lower and place real limits on what we can afford. A nurse in hospital looking after me would cost considerably more but hospital admission is need from time to time to give my wife respite.

(Consumer, South Australia, Submission #77)

We need to redefine and reconsider the value we place on caring. What I do know is that carers are not truly valued… They have no real financial value placed on their work – it is not factored fully into the running of our economy.

(Anonymous, South Australia, Submission #44)

6.4.8.3.11 Cost of medication

With complex issues regarding difficulties in accessing services, especially during the onset of illness and recovery phase, barriers to employment, lack of available supported accommodation or other housing / accommodation options, many consumers experience short and long term financial difficulties. One consumer expressed concern at his inability to afford necessary medication despite holding a pension card:

Although I have a pension card cheaper pharmaceuticals [sic] it still costs a lot regularly especially if like me you have other ailments. They only become free in December when I reach the safety net.

(Consumer, South Australia, Submission #77)

6.4.8.3.12 Health in rural and remote areas - collaboration between State and Federal Governments to improve services in rural and remote areas

As outlined previously in Section 2.8.4, the Medical Specialists Outreach Assistance Program, funded by the Federal Government, is a positive example of how integration and collaboration has worked successfully to enhance mental health services to Indigenous communities living in rural and remote areas of South Australia.

The Medical Specialist Outreach Assistance Programme in South Australia – Improving services to rural and regional areas November 2003 marks the second anniversary of the expansion of visiting psychiatric services to rural South Australia under the Medical Specialist Outreach Assistance Programme (MSOAP)… The MSOAP-funded psychiatrists now visit 20 towns and communities in rural and remote South Australia. They provide consultation-liaison services that emphasise the upskilling of local general practitioners (GPs) and other health-care workers. Although most of the visiting psychiatrists provide adult services, child psychiatrists now visit four regional centres. The child psychiatry services have been an important development for MSOAP because this is an area of special need and clinician numbers are quite limited. Local child mental health services are highly desired. The disruption to family life is substantial when a child is ill and treatment always involves the inclusion of one or both parents and often other family members. If treatment occurs in the capital city, there is inevitably a major disruption to the family routine, with substantial stress arising from the added costs and social dislocation. Furthermore, the provision of child psychiatric services in the local community facilitates the mobilisation of the community resources for the immediate treatment and ongoing management of the child's condition. The new MSOAP services are likely to improve continuity of care and will help prevent future complications and trauma, both for the patient concerned and the local community. Indigenous South Australians are also beginning to benefit from MSOAP initiatives. (author’s emphasis)

(Clinician, South Australia Submission #274)

6.4.8.3.13 Criminal Justice System - collaboration with the Adelaide Magistrates Court to provide services to, and reduce offending by, people with mental illness

As outlined previously in Section 2.8.4, The Magistrates Court Diversion Program is an example of a successful collaborative link to enable the criminal justice system to identify and deal more appropriately with people with mental illness who come before the court and are charged with a summary or minor indictable offence.

The Magistrates Court Diversion Program – Diverting people with mental illness out of the criminal justice system

The pilot Magistrates Court Diversion Program (MCDP), which commenced operation in the Adelaide Magistrates Court in August 1999, was the first ‘problem solving' court in Australia designed to deal with offenders with mental impairment… The impetus for this court came, in part, from South Australia 's then Chief Magistrate who recognised that courts needed to improve their ability to identify and respond to people who had a mental impairment. He noted that people “who did not belong in the criminal justice system” were continually appearing before Magistrates and were “being punished for things which were nothing but a manifestation of their problems” (Alan Moss, 1999).

Aims and Objectives of The Magistrates Court Diversion Program … The MCDP was designed to ‘better ensure that people with a mental impairment who come before the court have access to appropriate interventions that will assist in addressing their offending behaviour' (Justice Strategy Unit, 2000). Overall then, in line with other courts predicated on a therapeutic jurisprudence model, the aim was to use the defendant's contact with the criminal justice system as a vehicle for providing a treatment and support program designed to effect behavioural change.

Description of The Program Persons suspected of a mental impairment and who are charged with a summary or minor indictable offence are referred to the program, generally at the time the charges are laid. Upon referral, the individual is assessed to determine his/her suitability for the program. At that time, the defendant's willingness to participate is also ascertained. Those who do not want to participate are referred back to the normal court process. If a defendant is accepted onto the program, his / her case is then adjourned and an individualised intervention plan is developed which outlines appropriate intervention strategies designed to address the individual's mental impairment issues, any associated factors such as homelessness, and drug and alcohol addiction. For many clients who are already in treatment, the program aims to reinforce and support their continued engagement with their treatment or service provider. For others, it may involve referral to new treatment agencies and services. It should be noted that the court itself does not provide treatment. Instead, the client is referred to existing treatment and service providers… At the end of the program (which generally extends for between 4 to 6 months), the charges against some defendants are withdrawn by prosecution. In the majority of cases, though, the defendant is sentenced, with his / her progress while on the program taken into account at that point. The majority of defendants are given a good behaviour bond.

Evaluating The Program … Overall, the results showed a reduction in both the number of participants who were apprehended for offending post-program compared with pre-program, as well as a reduction in the actual number of incidents charged against this group. In particular: There was a significant reduction in the number of participants who offended as well as in the number of incidents detected post-program. Two thirds (66.2%) of program participants did not offend during their post-program year1. At an individual level, just over three quarters (76.4%) of the participants either became non-offenders or were charged with a smaller number of incidents post-program. Although these findings must be treated with caution, they suggest that the program may be having a greater impact on the more serious pre-program offenders… These findings… auger well for its future.

(from Skrzypiec, Wundersitz & Mcrostie (2004) Magistrates court diversion program – An analysis of post-program offending – Evaluation findings [Short report])

(Office of Crime Statistics and Research, Attorney-General's Department, Government of South Australia, South Australia Submission #278)

6.4.9 STANDARD 9: SERVICE DEVELOPMENT

The MHS is managed effectively and efficiently to facilitate the delivery of coordinated and integrated services.

The system doesn’t reflect the clients’ needs – the system is more interested in reflecting KPI’s [Key Performance Indicators] / good outcomes / indicators so they don’t deal with the difficult ones. These are the ones that are given the bus tickets from other places and they end up here in our community. I know this happens.

(Police Officer, South Australia, Murray Bridge Forum #16)

Under this Standard, submissions and presentations indicate concerns about:

• the current state of mental health services;
• the lack of resources and services and the impact of this on clinicians;
• the lack of services in rural and regional areas;
• the model of mental health care needs to change as there are insufficient community-based services and there is an inappropriate focus on inpatient and crisis care;
• lack of consultation with consumers, carers and staff;
• lack of mechanisms to improve service delivery and accountability;
• lack of funding;
• affordability of care - public versus private;
• problems with funding arrangements for service providers;
• lack of funding and services for young people; and
• a shortage of mental health professionals.

6.4.9.1 Current state of mental health services

The Rann government’s inaction on community mental health services can only be described as contempt for South Australians affected by mental illness.

(SANE Australia, National, Submission #302)

Doctors and mental health people will not give us what is necessary to help my son. There are often throw away comments such as “the mental health system is not working”, “there’s not enough money”, “there’s little that can be done”, “he has to seek the help”.

(Carer, Mother, South Australia, Submission #11)

If you spend more dollars on an inefficient and traumatising system, without reforming and modernising first, it will not only be a waste of time, energy and dollars, but will result in a larger mess than before.

(Consumer, South Australia, Submission #335)

On a personal note, there seems to be this amazing reform occurring in SA (so they say anyway). A great deal of money has been allocated but it seems to be for Capital Works. The future for SA seems to be that we will have lovely new buildings / wings etc but of great concern will be the lack of well educated and supported workforce dealing with clients with very specific needs. The lack of supports etc when the client goes home?? We will see terrific buildings but I am very concerned that the foundations are faulty. The foundations of mental health do not only belong within the hospitals / clinics they need to stretch out further into the communities - reinforcement needs to extend itself. We have seen the problems that have occurred in Western Australia and are aware that it could so easily occur here.

(Anonymous, South Australia, Submission #61)

[N]ot much has changed in the country Post Burdekin… A few years ago (but since Burdekin) my brother in law hung himself - in his shed in a country town. This followed at least 2 prior attempts. Although he presented to the local GP at no time was he detained or in receipt of anything close to resembling reasonable psychiatric care. His poor mental health was long standing… Everyone in town also knew about his alcohol addiction… the treating GP had treated many of [his family] for many years… so he knew who & what he was dealing with… I believe that he left a note which was quite readable and was able to make the necessary arrangements to hang himself in a space some distance from his home. On his 2 previous attempts (and there could well have been more) he was unsuccessful because the methods offended his sense of not wanting to make a mess - and he didn't get any appropriate help. Given that that GP is still the dominant medical officer in town & not much else has changed in terms of service availability, I don't think my brother in law's prognosis would be any different today. Now I fear for his son's life.

(Family Member and Service Provider, South Australia, Submission #34)

6.4.9.2 Lack of resources and services and the impact of this on clinicians

We have some excellent workers but they aren’t resourced to be able to provide the sort of care people need.

(Anonymous, South Australia, Adelaide Forum #9)

Many presentations were made at forums indicating the negative impact on staff of lack of resources and lack of other services to assist with the delivery of quality treatment and support to consumers and their carers. Feelings of burnout, ‘craziness’ and stress were reported and observed by clinicians and consumers.

I am a clinical psychologist and I left the mental health system because of burnout and the feeling that in my previous role I felt like I was perpetuating the abuse because I didn’t have the resources I needed to do my job properly.

(Anonymous, South Australia, Adelaide Forum #12)

I work as a clinical psychologist in the mental health service. Some days I feel crazy each day.

(Clinician, South Australia, Adelaide Forum #11)

Staff conditions… day-to-day conditions are so poor we struggle to work.

(Clinician, South Australia, Adelaide Forum #11)

Staff turnover in the mental health services is very high. We’re lucky if we get an allied health worker to stay for 3 months.

(NGO Worker, South Australia, Adelaide Forum #24)

6.4.9.3 Distribution of services – lack of services in rural and regional areas

…there has been ongoing debate regarding the mal-distribution of medical services in Australia… The majority of medical services have been concentrated in capital cities and major regional centres and have been quite limited in rural and remote areas. It has become increasingly difficult to recruit and retain general practitioners (GPs) in country areas and there is a long history of difficulties in the provision of specialist services outside large population centres. It is a fact that there are relatively few medical specialists living and working outside major regional centres… For example, in South Australia in 1997, only 1.1% of psychiatrists lived outside Adelaide.

(Clinician, South Australia, Submission #274)

One of the key concerns expressed both directly and by implication, and particularly at the Murray Bridge Forum, was of the lack of services in rural and remote areas of South Australia. Many consumers and carers spoke of the absence of any service to access and their only options were at a great distance away. Due to the scarce number of services, these services are difficult to access (e.g. long waitlists) and involved great disruption on a daily or long-term basis. Additionally, if long term treatment or supported accommodation is required, this involves removal of consumers, and sometimes carers, from social support networks and employment, and often at considerable financial cost.

Historically, specialist services to rural and remote areas have generally been provided on a visiting private practice basis, sometimes with State Government or local area funding support. In more recent years with the development of tele-conferencing facilities, it has become possible to provide a number of services at a distance from a capital city base. Psychiatric services are a good example of this and tele-psychiatry consultations have been performed by the Rural and Remote Mental Health Service of South Australia since 1994.

(Clinician, South Australia, Submission #274)

The hospital facilities for regional South Australians needing inpatient treatment are in the city (Glenside Hospital) which means that hospital patients with a mental illness who come from country areas such as the Murray Mallee are removed from their families and networks. Secure hospital facilities in regional areas are needed.

(Health and Community Services Network, Murray Mallee Strategic Task Force, South Australia, Submission #115)

As mentioned previously, the Medical Specialist Outreach Assistance Programme has improved access in rural and remotes areas.

The new MSOAP services are likely to improve continuity of care and will help prevent future complications and trauma, both for the patient concerned and the local community. Indigenous South Australians are also beginning to benefit from MSOAP initiatives.

(Clinician, South Australia, Submission #274)

What has improved in the South Australian Murray Mallee region:

•  There are more mental health workers in the region than there were 10 years ago, which has given some people with mental illness better access to supports.

•  The Mental Health Line / Rural and Remote Triage has helped to reduce the isolation for those in the region who suffer from mental illness and for those who support them.

•  Telemedicine and videoconferencing facilities have enabled more people to have access to psychiatrists.

•  Recent group programs such as the women's strength-building course have assisted women in the region to enjoy improved mental health and self confidence.

(Health and Community Services Network, Murray Mallee Strategic Task Force, South Australia , Submission #115)

Despite these improvements, however, the evidence presented suggests that the model of service and resource distribution across South Australia needs to fundamentally change in order to ensure that the rights of consumers and their families are protected. This included access (according to Standard 11.1; equitable access) to treatment and support services for all stages of the recovery process (according to Standard 11.4) as well as access to supported accommodation (Standard 11.4.B) and services to support the consumer’s quality of living (Standard 11.4.A).

We don’t have enough workers here – our workers are always stressed. We can’t expect much off them. One of the things we will do will be to lobby government. (Consumer & Advocate, South Australia, Murray Bridge Forum #8)

As recommended by the Health and Community Services Network, Murray Mallee Strategic Task Force, access to both community based services and acute care treatment facilities (for example, closer proximity) need to improve.

Recommendation: That funding is allocated to community support services in rural areas (and not just for those living in regional centres) to supplement clinical mental health services. These services should include programs aimed at reducing social isolation, developing confidence and self esteem and promoting integration into the wider community. These programs should also include support for people with a mental health disability to return to study or work.

(Health and Community Services Network, Murray Mallee Strategic Task Force, South Australia, Submission #115)

Recommendation: That secure facilities for mental health patients are provided in regional hospitals with staff trained in psychiatric nursing and associated allied health professions.

(Health and Community Services Network, Murray Mallee Strategic Task Force, South Australia, Submission #115)

Two submissions also highlighted staffing issues. The first argues that any plan to increase services in remote and rural areas needs to address staff recruitment and retention issues which have hindered the filling of vacancies in the past.

There are a number of reasons why it has been so difficult to attract specialists to work and live in country areas… These include the isolation from peer support, the demands of families, including the career needs of the spouse and the educational and other needs of children, as well as likely future difficulties in returning to metropolitan practice. There can also be problems in limiting service demands and the potential for associated 'burnout'. Furthermore, there are the unique stresses associated with living in a small community where there is a lack of anonymity and the likelihood of more intense public scrutiny of one's day-to-day activities. There may be financial disincentives associated with working in country areas. There can be major difficulties for the clinician in providing for his or her emotional and professional needs. For example, it can be hard to establish and maintain support networks locally, particularly for clinicians working in such an emotionally intense area as psychiatry. It is also hard to provide for one's recreational needs, including holidays, because there may be a limited availability of local support and after-hours back up, and the likelihood of having to deal with clinical emergencies after hours would be particularly draining. Finally, there are often major constraints upon the opportunities to engage in regular professional development and ongoing educational activities, such as attending conferences and medical college seminars.

(Clinician, South Australia, Submission #274)

There is [sic] not enough nurses, social workers and psychiatrists in the country where as in the city there are more however even in the city staffing in the mental illness field is less than satisfactory.

(Consumer, South Australia, Submission #77)

6.4.9.4 Model of mental health care needs to change – lack of community-based services and inappropriate focus on inpatient and crisis care

Concerns were expressed about the model of mental health care underlying service delivery and planning in South Australia. Concerns were raised about the emphasis on inpatient and crisis care and the medical model. Concern was also raised regarding ‘re-institutionalisation’ as people with mental illness are now being diverted and ‘institutionalised’ in prisons. This emphasis needs to change to improve outcomes for people with mental illness.

There have been three mental health plans since the Burdekin Report. There have been great advances in medication – there have been great collaborations with GPs and other reforms with strong evidence bases and new technologies developed. But we remain one of the lowest spending countries in terms of what we spend on mental health care. We spend almost half what other countries spend. We spend very little on supported accommodation where it’s really needed and we still spend a lot on inpatient or crisis care. The problem is that we are locked into an old model. The evidence suggests that people do need supported accommodation – but the system has been poorly funded in SA. (NGO Worker, South Australia, Adelaide Forum #22)

This institutional model extends into the prison system. The Chair of the SA Parole Board has drawn attention to the high number of people with a mental illness in the State’s prisons, saying the government was using them as a ‘sump’ for people who should be cared for by mental health services.

(SANE Australia, National, Submission #302)

I am extremely concerned about the use of restraint and seclusion in SA hospitals. There have been frequent recent stories of psychiatric patients being shackled in the ED [Emergency Department] at central city hospitals, inappropriate use of seclusion (for staff convenience not patient care), the use of outmoded and banned restraint holds by nurses and patients not being treated with the care and respect they deserve.

(Academic, South Australia, Submission #142)

We’ve got a 19th century hospital system with 21st century demands.

(Anonymous, South Australia, Adelaide Forum #9)

We have medicalised something which is not necessarily medical – there are potentially harmful side-effects. For a start it takes away ownership of the problem/the illness.

(Academic, South Australia, Submission #219)

[Recommendation] Decisive action by the State government to reform South Australia’s mental health services in consultation with the Mental Health Coalition of SA – committing political will and resources to close Glenside and implement community-based services, with acute wards mainstreamed into general hospitals and a new forensic facility.

(SANE Australia, National, Submission #302)

We need more emphasis on people’s social & spiritual needs.

(Social Worker, South Australia, Adelaide Forum #20)

The mental health system here in South Australia is too weird for me.

(Carer, Family Member, South Australia, Adelaide Forum #2)

6.4.9.5 Lack of consultation with consumers, carers and staff

Concerns were expressed about the lack of consultation with clinicians, consumers and carers in the planning and delivery of mental health services. According to Standard 9.8, a strategic plan is to be ‘developed and reviewed through a process of consultation with staff, consumers, carers, other appropriate service providers and the defined community’. Clinicians and consumer advocates spoke of the need for genuine consultation, ‘to be heard’ about their needs and to contribute innovative ideas to solve service delivery problems.

…there is a tokenistic response to staff who have innovative ideas – great program.

(Clinician, South Australia, Adelaide Forum #11)

There is a token approach to consumer and carer participation – tokenistic responses. There is no carer and consumer input. No feedback.

(Clinician, South Australia, Adelaide Forum #11)

There’s a need for a rural consultation in areas like Port Augusta. There are huge workloads for staff and GPs in our area… There’s also a need for consumers, carers etc to be heard and to be supported with funding.

(Advocate, South Australia, Adelaide Forum #15)

The following statements from a clinician provide just one example of the tokenistic responses experienced by those staff who seek improvement of the mental health services, and of the repercussions that may be experienced for attempting to do so.

It is evident to clinical staff that contributions to policy formulation or micro-reform suggestions aimed at service improvement are not welcome. In the rare instances where consultation processes exist they are tokenistic, without power and their outcomes are not acted on. When suggestions / proposals are submitted they are ignored as a rule. If the person making suggestions, raising issues insists, s/he will be increasingly ignored, and should s/he persist, s/he will be marginalised, described as having a 'bee in his / her bonnet' or 'a chip on his / her shoulder'. This may gradually degenerate in outright denigration of his / her work or person on the part of managers, team leaders, including character assassination which outside of the Public Service would be subject to slander and libel laws.

(Clinician, South Australia, Submission #56)

Day to day working conditions within the mental health services are often so poor that staff are struggling to contend with the daily issues of accommodation, equipment, safety provisions and aspects of managerial culture. Consequently, staff are less able to address the more complex issues of service reform. A culture of inertia and hopelessness sets in, as staff are forced into a position of simply having to cope with less than adequate working conditions.

(Clinician, South Australia, Submission #56)

As with the tokenistic responses to consumer and carer participation, staff initiatives for service improvement frequently remain unsupported, if not discouraged… Staff advocacy for the development of a hospital at home program was similarly discouraged and a proposal to aid the development of culturally appropriate service has been unsupported. Whilst it is apparent that not all proposals can, or should, be supported, the more fundamental issue that is being raised here is of a culture that does not foster the development and implementation of new ideas, but which actually might be seen to discourage them. Further, questions must be raised as to the commitment to the National Mental Health Strategy.

(Clinician, South Australia, Submission #56)

6.4.9.6 Lack of mechanisms to improve service delivery and accountability

Associated with concerns about an inability to contribute in a positive manner to service improvement are concerns about speaking up and fear of consequent reprisal. Accountability ensures the protection of rights of people with mental illness and practices to ensure delivery of quality care. Standard 9.2 states: ‘There is single point accountability for the MHS across all settings, programs and age groups’, and Standard 9.29 states ‘The MHS has an evaluation strategy which promotes participation by staff, consumers…’.

I have advocated in the past on behalf of a mental health worker who wanted some changes to occur - because they are employed by the system they get into trouble if they speak up, they can’t speak up.

(NGO Worker, South Australia, Adelaide Forum #24)

Sheer bullying and harassment of staff who speak out is a problem – we need to strengthen the culture. The Equal Opportunity Act in South Australia still doesn’t include mental health – we know it will be on the table in September and we would appreciate your support.

(Clinician, South Australia, Adelaide Forum #11)

6.4.9.7 Lack of funding

Along with reports about the need for increased funding and services for many vulnerable groups described elsewhere in this Report (for example for children and youth with mental health and drug and alcohol problems) one consumer advocate expressed particular concern about the lack of funding for people with co-occurring physical disability and mental illness or mental health problems. The health care needs (both physical and mental) for people with physical disability beyond those directly associated with their specific physical disability are a common problem faced by this group. SANE Australia’s SANE Mental Health Report 2004 also discusses funding concerns.

I am here representing people with physical disabilities who also have a mental health problem… The funding is extremely important, we need adequate funding for appropriate services.

(Consumer and Advocate, Female, South Australia, Adelaide Forum #3)

While other jurisdictions spend around 47% of the mental health budget on hospitals, South Australia spends a massive 60% – in fact, around 45% of the entire mental health budget continues to be swallowed up by Glenside Hospital.

(SANE Australia, National, Submission #302)

As well as limited funding for community-based clinical services, the proportion of the mental health budget allocated to non-government organisations providing community support has shrunk to a minuscule 1.9%. The key area of supported accommodation receives just 0.4% of the mental health budget (compared to 17.9% in better funded States).

(SANE Australia, National, Submission #302)

Some additional funding has been released for mental health services since 2002, primarily for clinical services and often on an ad hoc basis. This includes a welcome $11.4 million for supported residential facilities and extra support for case management. A further $800,000 has been spent to increase security at the Glenside Psychiatric Hospital – mainly, it would seem, in response to local media ‘beat-ups’ about patients leaving the grounds (whom they misleadingly describe as ‘inmates’ who ‘escape’ and have to be ‘recaptured’).

(SANE Australia, National, Submission #302)

6.4.9.8 Affordability of care: public versus private

In contrast to the many concerns raised by consumers, carers, clinicians and academics about the quality of public mental health service delivery in South Australia, the following report from a carer at the Adelaide forum is potentially an indicator of a growing trend in health care: that only those with the financial resources can access ‘marvellous’ mental health care.

The Adelaide clinic (private clinic) has been marvellous with our family and the new young shrink has been marvellous.

(Carer, Family Member, South Australia, Adelaide Forum #2)

Also of serious concern, was the following remark made by a consumer who was unable to find a bulk billing psychiatrist and making it difficult to access care if she was struggling to pay the gap required.

But then the problem in Adelaide if you can get up there is that there’s very little bulk billing by psychiatrists in Adelaide. Earlier in the year I was told that I needed a psychiatrist but I couldn’t find one that was bulk billing that was taking new patients.

(Consumer, South Australia, Murray Bridge Forum #2)

6.4.9.9 Problems with funding arrangements for service providers

Concern was expressed regarding funding arrangements for services, the brevity of the contracts, the competitive tendering process and the negative impact these processes have had on collaborative arrangements between agencies:

I am currently trying to set up [Y] for residents of Supported Residential Facilities in Adelaide under a new funding arrangement. While this all sounds wonderful, I have serious reservations some of which tend to be funding based:

•  our funding is only for 12 months at a time and there is pressure on us from 'bureaucrats' to provide them with data to prove we're achieving outcomes which are still vague but in the realm of a long term research project & have no relationship to the level of chronic ill-health - mental & physical) & the level of dysfunctionality due to long term institutionalisation. Initially I was led to believe that the funding would be for 4-5 years (1 year of service delivery has been lost while bureaucrats thought about what to do) but it seems we'll only be funded year-by-year for up to 4-5 years. This has implications for planning effective services, recruiting staff etc.

•  some of the new services are to be provided by NGOs. Prior to the tendering process for provision of these services, there was significant & positive collaboration between all of the NGOs & govt agencies - this level of collaboration has now diminished to include those agencies receiving specific funding - we've lost a pool of partners because of a competitive tendering process.

(Family Member and Service Provider, South Australia , Submission #34)

6.4.9.10 Lack of funding and services to meet the needs of young people

The Youth Affairs Council of South Australia expressed concern that the level of funding allocated to youth services and programs was inadequate to meet the mental health needs of young people and called for equitable distribution of mental health funding;

The greatest burden of disease for young people is mental health. In 2000-2001, up to 20% of young people aged 12 to 17 and more than one quarter of 18 to 24 year olds experienced mental health issues, making mental health a strong priority for YACSA in this submission. Funding allocated does not reflect the significant impact mental health issues have on young people, and YACSA contends that a more equitable distribution of mental health funding to young people should be determined…

(Youth Affairs Council of South Australia, South Australia, Submission #38)

 

Because of concerns that homeless young people with high and complex needs including mental health issues are not being well served by accommodation, support and health services, YACSA has conducted consultations with providers and consumers. The key findings of those consultations are also supported by various recent reviews and research into this area… In summary the findings are that services are characterised by:

•  High and increasing demand associated with the combination of mental health problems and homelessness leading to higher rates of hospitalisation, arrest, misuse of alcohol and drugs etc

•  Increasing numbers of young people presenting to agencies with an increasingly severe range of problems in relation to:

•  Sexuality related issues
•  Behavioural problems
•  Substance abuse
•  Depression / anxiety
•  Violence/anger
•  Grief / loss
•  Homelessness
•  Physical and / or sexual abuse

•  Fragmentation of services, especially given that clients usually present with multiple needs that may require the involvement of multiple agencies across several sectors

•  A tendency for 'difficult' clients to be 'handballed' to other services – that is, referred without any communication between agencies

•  A particular shortfall in supported residential services with access to mental health outreach and support

•  A concentration on highly focused, short term, acute crisis management casework at the cost of continuity of care and a community development capacity

•  A pressure to meet the funding body numbers – output not outcomes

•  Restrictive eligibility criteria (age, geographic, diagnostic and behavioural) especially for high need / severe cases, leading to exclusion and consequent exacerbation of mental health issues, homelessness, and associated problems

•  Poor communication across sectors, characterised by confusion about respective roles and expectations

•  A lack of flexibility of response from many agencies, failing to address the widely varied immediate needs of young people, and therefore failing to engage with them

(Youth Affairs Council of South Australia , South Australia , Submission #38)

One major consequence of this situation is that a relatively small number of young people with high and complex needs, whose extreme and repeated behaviours have effectively excluded them from SAAP [Supported Accommodation and Assistance Program] accommodation and other supports, are relying on hospital admissions for accommodation and support and creating a significant demand on police and the criminal justice system. The costs to government incurred by this small group are substantial. This proposal argues that a comparatively small investment in a new capacity–building service could significantly reduce these costs.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

6.4.9.11 Shortage of mental health professionals

Associated with the lack of services are reports of an excessive demand for the services that exist, and reports that these services often had difficulties recruiting and retaining staff. The shortage of qualified mental health professionals was noted as a critical problem:

Firstly, one of the areas we have had difficulty in is finding workers that have training or experience in working with people with mental illnesses. Much training is based around aged care or general disability. We would like to provide more support to carers of people with mental health conditions but we need to ensure that we have appropriate, qualified workers available to assist with the respite care. Secondly, one of our constraints is that we cannot provide respite care if it is an “at risk” situation for the worker. If a person is having an acute episode, we may not be able to provide respite care to allow the carer to have a break- hospital admission may be the only option.

(Service Provider, South Australia, Submission #57)

6.4.10 STANDARD 10: DOCUMENTATION

Clinical activities and service development activities are documented to assist in the delivery of care and in the management of services.

Under this Standard, submissions and presentations indicate concerns about:

• documentation systems not being utilised; and
• carer’s plea for access to be corroborated with clinical records ignored.

6.4.10.1 Documentation systems not being utilised

Standard 10.2 states ‘Treatment and support provided by the MHS are recorded in an individual clinical record which is accessible throughout the components of the MHS’ and Standard 10.4 states ‘A system exists by which the MHS uses the individual record to promote continuity of care across settings, programs and time’. According to one NGO worker this is not occurring and consumers are becoming frustrated at having to tell their stories repeatedly. Additionally, if records are not being accessed, this would also imply that clinicians are also not entering data regarding any interventions (Standard 10.5, ‘Documentation is a comprehensive, factual and sequential record of the consumers’ condition and treatment and the treatment and support offered’) and signed and dated (Standard 10.3).

The system is stuffed and so difficult for consumers to navigate. People have to tell the stories over and over again to a range of different people. They should only have to tell their story once.

(NGO Worker, South Australia, Adelaide Forum #24)

6.4.10.2 Carer’s plea for access to be corroborated with clinical records ignored

In one submission a mother highlighted a problem with accessing care for her son and hoped that his record could be used to corroborate his need for treatment as he was too ill to request the help himself.

I rang ACIS (Assessment and Crisis Intervention Service) on the afternoon of 27/2 [2004] in an attempt to understand how things had gone so wrong. [Y] told me that there had been several phone calls made to [X] by ACIS and that he had not wanted intervention!!! We are referring here to a man who… HE HAS NOT BEEN WITHOUT SOME FORM OF TREATMENT OR DETENTION ORDER SINCE ABOUT 1988 AND HE WAS CONTINUALLY UNDER... DETENTION AND OR COMMUNITY ORDERS IN THE PRECEEDING FIFTEEN MONTHS. There is an ample collection of SA files on [X]… (author’s emphasis)

(Carer, Mother, South Australia, Submission #279)

6.4.11 STANDARD 11: DELIVERY OF CARE

Principles guiding the delivery of care: The care treatment and support delivered by the mental health service is guided by: choice; social, cultural and developmental context; continuous and coordinated care; comprehensive care; individual care; least restriction.

Under this Standard outlining the principles underlying care, submissions and presentations indicate concerns about:

• the lack of choice and individualised and continuous care currently available in mental health services.

Further evidence supporting this is presented under other subsections of this Standard.

6.4.11.1 No choice, no continuous care, no individual care

The family is facing another situation of the ultimatum between participating in the complete program with suspension of their preferred treating professionals, or repeating the above process with no guarantee that there will be another premature discharge that places the young person’s life at risk, let alone another experience of not being heard, and no willingness for collaboration that works toward shared approaches and negotiated goals wherever possible.

(NGO Service Provider, South Australia, Submission #233)

This example presented by an NGO service provider raises serious concerns that nearly all the underlying principles governing the delivery of care are not being implemented resulting in the young person’s life being placed at risk. Other similar concerns were expressed at the forum held in Adelaide:

People need choice – the current system doesn’t afford choice – it’s falling over.

(Social Worker, South Australia, Adelaide Forum #20)

I’m really disgusted with the situation, I went to a mental illness conference in Canberra last year and heard someone say that people are treated like ‘objects’ – I believe that because that’s what it’s like in Adelaide.

(Carer, Consumer & Advocate, South Australia, Adelaide Forum #5)

In the country you don’t have a choice of psychiatrist, and there is no alternatives [sic] when it comes to what is available to help you. There is no therapy, little in the way of counseling [sic] and no choice but to do your own rehabilitation.

(Consumer, South Australia, Submission #77)

An extreme example of the consequence of the inability of one mother to obtain the care, treatment and support she required for her son was that she decided she could no longer care for him and made him a ward of the State.

[X] became a ward of the state because I was aware I needed help with his personality changes and respect for himself.

(Carer, Mother, South Australia, Submission #195)

6.4.11.1 Access

The MHS is accessible to the defined community.

Under this Standard, submissions and presentations indicate concerns about:

• attitudes towards Indigenous people;
• operational policies which limit access (opening hours and mode of contact);
• a crisis is required before services can be accessed;
• carers concerns are being ignored;
• long waitlists or no clinicians available at all;
• lack of services for people with mental illness and complex needs; and
• lack of services for people with personality disorders.

An inability for consumers to access treatment and support services, both within the community and inpatient care, often results in a whole series of rights being infringed for consumers, carers and the community. For the consumer, the consequences of these infringements can include consequences ranging from increasing disability, and hence consequent inability to care for oneself or others, participate socially or work or study, to (in some cases) the potential for harm to self or others, and to becoming poor and ultimately homeless. Increasing disability can also further expose the consumer and their family to discrimination and social exclusion, further compounding their illness.

For children and youth, failure to gain access to services at this time of their life can place their future life course at risk. For example, if they are expelled from school, their problem behaviours can increase, further disrupting their relationships with their peers.

Similarly, increased burdens on carers can disrupt their ability to participate socially and work when their family member became increasingly ill and require increasing care. Family isolation and increasing instability were also frequently reported due to the lack of community support and acceptance (high levels of stigma and discrimination) and lack of family-centred approaches to treatment and support. For the community, rights to safety can be infringed upon and social and economic cohesion disrupted.

6.4.11.1.1 Difficulties being experienced by Indigenous people

The main problem for Indigenous people is that people are so judgemental of Indigenous people. Our clients are most often judged as taking drugs or alcohol and not being mentally ill. Because of this, because it’s easy to say they’ve taken something, they receive no mental health care. It’s very hard when we go to government services for care.

(Clinician, South Australia, Adelaide Forum #13)

According to Standard 11.1.1 ‘The MHS ensures equality in the delivery of treatment and support regardless of consumer’s age, gender, culture, sexual orientation, socioeconomic status, religious beliefs, previous psychiatric diagnosis, past forensic status and physical or other disability’. Despite this, concerns were expressed regarding the inability of Indigenous people to access care due to discriminatory attitudes and beliefs. As a result, care has been denied to Indigenous people. As an example of the barriers experienced by Indigenous people, a clinician at the Adelaide forum described the lengths one Indigenous person went to access care:

…Indigenous people… I want to tell you about a guy that I saw on the streets. He went to the Royal Adelaide Hospital to seek treatment and they basically told him to piss off. I picked him up off the streets with 2 broken legs and a broken hip. He jumped off the bridge so he could get help.

(Clinician, South Australia, Adelaide Forum #13)

By contrast, at the Murray Bridge Forum, a more positive picture was described with regards to services for Indigenous people as a result of the involvement of Indigenous workers. Unfortunately, services appear limited due to lack of resources.

We have a high population of indigenous people. The indigenous workers are great but they are so stretched. We have data from York Peninsula from programs they have run there that shows that if people with a mental illness are supported to break down their social isolation then they do get better and it aids with their rehabilitation.

(Community Health Service worker, South Australia, Murray Bridge Forum #9)

6.4.11.1.2 Operational policies are limiting access (opening hours and mode of contact)

Standard 11.1.4 states: ‘The MHS is available on a 24 hour basis, 7 days per week’ and Standard 11.1.3 further states ‘…in a convenient and local manner’. One police officer expressed concern that as a result of services only being available during office hours, the police service was the de facto after-hours service. This is of grave concern on many levels, not the least of which is the stigma for the consumer and their carers resulting from contact with the police which is misinterpreted as threats to safety or criminality.

I see a r