PART TWO : KEY SUMMARIES

• 2.1 Mental health and human rights in Australia
  • 2.1.1 International human rights and the right to mental health care in Australia
  • 2.1.2 A summary of changes in Australian policy and practice since the Burdekin Report
  • 2.1.3 Human rights and the National Standards for Mental Health Services
• 2.2 Key themes from national consultations and written submissions
  • 2.2.1 Themes relating to the national government, National Mental Health Strategy and national recommendations
  • 2.2.2 Key national themes that emerged from the review of service environments within each State / Territory
• 2.3 National survey of mental health priorities implementation
• 2.4 National survey of consumer and carer experiences
• 2.5 National Mental Health Report 2004
• 2.6 Australian progress against WHO recommendations
• 2.7 State / Territory reviews
  • 2.7.1 New South Wales
  • 2.7.2 Victoria
  • 2.7.3 Queensland
  • 2.7.4 South Australia
  • 2.7.5 Western Australia
  • 2.7.6 Australian Capital Territory
  • 2.7.7 Northern Territory
  • 2.7.8 Tasmania

2.1 MENTAL HEALTH AND HUMAN RIGHTS IN AUSTRALIA

2.1.1 INTERNATIONAL HUMAN RIGHTS AND THE RIGHT TO MENTAL HEALTH CARE IN AUSTRALIA

Perhaps it is time to frame the concerns of persons with mental disability not simply as a social problem, but as a human rights imperative.

(Gostin, 2004, p. 11)

It is commonly assumed that the only relevant human rights issues for people with mental illness in Australia relate to the protection from arbitrary detention and the right to humane and dignified care when treated in institutions. However, people with mental illness have exactly the same fundamental human rights as every other person, whether they are being treated in a hospital, or in the community. For example, everyone has the right to the highest attainable standard of health and the right to an adequate standard of living. The current international and national trend towards deinstitutionalisation and community-based care brings all those other rights into sharper focus.

Today, it is clear that, at least in relation to mental health problems, equality before the law should be complemented by equity in resource distribution, fraternity needs to be understood as solidarity with people who need help, and liberty should be interpreted in the light of duties and responsibilities that all of us should accept as members of societies that strive to be civic.

(Sartorius, 2002, p. 13)

The movement to consider the experiences of people with a mental illness within a human rights framework has gained momentum internationally. All countries struggle with the stigma and discrimination associated with mental illness and the negative personal, social and economic outcomes that arise due to inadequate health and social services. There is acknowledgement that human rights violations against the mentally ill are widespread, occurring both within and outside the delivery of health care (World Health Organization Europe, 2004). While many countries have attempted to tackle such violations by enacting legislation to protect such rights, some have argued that these measures have often failed to protect the rights of people with mental illness due to popular or political pressure (Gostin & Gable, 2004).

The shameful history of benign and sometimes malignant neglect of persons with mental disabilities is well understood: the deep stigma and unredressed discrimination, the deplorable living conditions, and the physical and social barriers preventing their integration and full participation in society. Countless promises have been made to right the wrongs, but new forms of neglect have always emerged. The mentally disabled have ended up in prison, in equally deplorable adult homes, or on the streets, homeless and destitute, while the wider society has averted its eyes.

(Gostin, 2004, p. 11)

Human rights jurisprudence involving involuntary detention, conditions of confinement, civil rights and access to mental health services has been growing in Europe and the Americas (Gostin & Gable, 2004). With regards to improving access to quality mental health care, WHO Europe suggests that legislation “can make a difference in ensuring parity with other health services and ensuring that what is provided is appropriate to people’s needs” (WHO Europe 2004, p. 2). However, legislation is not of itself a guarantee against human rights violations (WHO Europe, 2004).

2.1.1.1 International human rights and the right to mental health care in Australia

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

(Universal Declaration of Human Rights, Article 25(1))

Providing the best possible health care is not just a desirable social goal, it is a fundamental human right and it applies to all people no matter who they are or what their illness. Associated with the concept of a ‘right to health’ is a growing body of international law of a ‘right to health services’ requiring ‘nation states to take affirmative steps to assure that residents of the country have access to population-based health protection measures and also affordable health care in the context of the nation’s economic resources and cultural mores’ (Kinney, 2001, p. 1458). The international human right to health is established both via international treaties and a growing body of international customary law (Kinney, 2001). There is growing recognition that international human rights law is a powerful means by which to advance the rights and interests of people with mental illness (Gostin & Gable, 2004; Quinn & Degener, 2002; Kinney, 2001).

The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

(International Covenant on Economic Social and Cultural Rights, Article 12)

Australia is a party to the International Covenant on Economic, Social and Cultural Rights (ICESCR; United Nations 1966a), the International Covenant on Civil and Political Rights (ICCPR; United Nations 1966), and the Convention on the Rights of the Child (CRC; United Nations 1989). Australia is therefore bound under international law to ensure that all people in Australia enjoy the following rights, amongst others:

• The right to the highest attainable standard of physical and mental health (Article 12 ICESCR; Article 24 CRC).
• The right to an adequate standard of living including food, clothing and housing (Article 11 ICESCR; Article 27 CRC).
• The right of children to an environment that fosters the health, self-respect and dignity of a children where they are in need of psychological recovery from neglect, exploitation, torture or trauma (Article 39 CRC).
• Where children have been placed under mental health programs they have the right to periodic review (Article 25 CRC) .
• The right of children with disabilities to access appropriate health and rehabilitation services (Article 23 CRC).
• The right to life (Article 6 ICCPR; Article 6 CRC).
• The right to freedom from cruel, inhuman or degrading treatment (Article 7 ICCPR; Article 37 CRC).
• The right to liberty and security of person (Article 9 ICCPR; Article 37 CRC).
• The right to be treated with respect for dignity and with humanity when deprived of liberty (Article 10 ICCPR; Article 37 CRC).
• The right to freedom of movement and choice of residence (Article 12 ICCPR).
• The right to freedom of interference with privacy or family life (Article 17 ICCPR; Articles 9 and 16 CRC).

In addition to the fundamental human rights enshrined in the International Covenants, there are specific UN Principles that deal with some of the particular issues facing people with mental illness.

The UN Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care (the UN Mental Health Principles; United Nations General Assembly, 1991) were adopted by the United Nations in 1991. While it is not a binding instrument in itself, the Commonwealth, State and Territory governments have recognised the value of incorporating those principles into policy, and attempted to do so in the First National Mental Health Strategy.

The UN Mental Health Principles reinforce the rights enshrined in the International Covenants and provide valuable guidance as to how those rights ought to apply to people with mental illness. For example Principle 8(1) makes clear that people with mental illness have the right to the same standard of health care as other ill persons and Principle 14 states that mental health facilities should have the same level of resources as any other health facility. Additionally, Principle 7 emphasises the right to be treated and cared for as far as possible in the community and Principle 9 emphasises the importance of ‘the least restrictive’ alternative in relation to treatment. The Burdekin Report treated the UN Mental Health Principles as a benchmark in determining whether or not the rights of people with mental illness were being protected (Burdekin Report; Human Rights and Equal Opportunity Commission, 1993, p31).

2.1.1.2 Recent international developments

The Council of Europe, comprising 45 member states, recently drafted a comprehensive set of recommendations to protect the rights of people with mental illness and to promote higher standards of care (Kingdon et al. 2004). The recommendations cover a wide range of areas including:

• the right to non-discrimination and mental health promotion;
• the right to be accommodated in appropriate environmental and living conditions while receiving treatment and support;
• the right to live and work in the community;
• limitations on the use of seclusion and restraint options of people needing treatment;
• criteria and procedures for involuntary placement and treatment;
• the right to individualised treatment;
• the right to treatment in the least restrictive environment;
• guidelines for the involvement of police (who should also receive appropriate training to respond appropriately), the courts and the prison system in the context of mentally ill persons; and
• guidelines for the treatment of ‘minors’.

In reforming systems to protect the rights of the mentally ill, the Council for Europe also emphasises the fundamental need for monitoring quality standards in the provision of mental health services (Kingdon et al. 2004).

In the context of the general trend towards deinstitutionalisation and the growing rate of homelessness, incarceration of people with mental illness and community fears of danger, recommendations from the Council of Europe also emphasise the need for vigilance to ensure that involuntary orders are made ‘for therapeutic purposes’ and not solely for the purposes of removing the person from the community:

Involuntary placement should include therapeutic purpose. The mental health system therefore should not be used for custodial reasons alone, even when there is significant risk of serious harm to others. Where such potential for harm exists but no therapeutic intervention is indicated, this is a matter for the criminal justice system.

(Kingdon, Jones & Lönnqvist, 2004, p. 277)

The World Health Organisation (WHO) (Project on Mental Health and Human Rights; WHO 2005a) is also currently preparing a mental health legislation manual to assist countries to develop a legal framework to protect the rights of people with mental illness both within the health delivery context and in the broader community. Specifically, within health service delivery environments, WHO “frames the right to mental health in terms of population-based services and would require that countries offer screening for mental illnesses, mental health education, and psychiatric services” (Gostin, 2004). On a broader level, WHO argues that while mental health legislation is not sufficient to address the rights of the mentally ill, it is an essential complement to mental health policy and provides the legal framework with which to meet its aims and that it is an evolving process:

Mental health legislation can provide a legal framework for addressing critical issues such as the community integration of persons with mental disorders, the provision of care of high quality, the improvement of access to care, the protection of civil rights and the protection and promotion of rights in other critical areas such as housing, education and employment. Legislation can also play an important role in promoting mental health and preventing mental disorders. Mental health legislation is thus more than care and treatment legislation that is narrowly limited to the provision of treatment in institution-based health services.

(World Health Organisation, 2003, p. 2)

In 2002, the United Nations Human Rights Commission appointed a Special Rapporteur on the Right to Health. The Special Rapporteur has the mandate to collect information on the realisation of the right to the highest attainable standard of physical and mental health and make recommendations on how to ensure compliance with that right (http://www.ohchr.org/english/issues/health/right/index.htm).

2.1.2 A SUMMARY OF CHANGES IN AUSTRALIAN POLICY AND PRACTICE SINCE THE BURDEKIN REPORT

Little since the Burdekin Report has changed save that the process of deinstitutionalisation has hastened. While patients who are involuntarily detained now possess a number of enshrined rights that regulate the circumstances of their detention, increasing numbers of still psychotic patients are discharged under pressure for hospital beds. Problems continue to exist with the coverage of disability discrimination legislation. No appreciable increases in resources has been allocated for the escalating numbers of significantly symptomatic patients cared for within the community. In such circumstances, there is a real limit upon the extent to which it can be said that those with mental illness have rights to treatment and, in particular, to adequate treatment. A real issue within mental health law, as increasingly it is in within the wider area of law, is how patients can insist, with the assistance of the law, upon being provided with the treatment that they need for the alleviation of their pain and suffering.

(Freckelton & Loff, 1998, 267 at p. 285)

While the aims of the Second [National Mental Health] Plan have been an appropriate guide to change, what has been lacking is effective implementation. The failures have not been due to lack of clear and appropriate directions, but rather to failures in investment and commitment.

(Steering Committee for the Evaluation of the Second National Mental Health Plan 1998-2003, 2003, p. 3)

The neglect of mental health services in our society has a long and well-documented history. The personal and family consequences of decades of neglect were highlighted for the whole nation by the widespread publicity given to the 1993 National Inquiry into the Human Rights of People with Mental Illness (The Burdekin Report; Human Rights and Equal Opportunity Commission, 1993). In response to growing criticism regarding the quality of mental health services in the early 1990s, state, territory and federal governments attempted to enshrine human rights protection into mental health care policies.

The first of these attempts was in 1992, when all Australian State and Territory governments, as well as the Commonwealth Government, agreed to develop a common National Mental Health Policy and Strategy. This gave birth to the first National Mental Health Plan which covered the five-year period from 1993 to 1998. The Plan demonstrated a commitment to a human rights based approach to the reform of mental health care in Australia. Specifically, in 1992 all State and Territory governments agreed to develop legislation by 1998 that was consistent with the UN Mental Health Principles (Rees 2003, p. 33).

In 1996 the Attorney-General’s Department developed a ‘Rights Analysis Instrument’ to measure compliance of State and Territory legislation with the UN Mental Health Principles (Watchirs & Heesom 1996). A review of mental health policies against that instrument found that the legislation did comply or that the Governments were in the process of appropriately amending their mental health legislation (Watchirs 2000).

Despite these advances, by 1998, when the Second National Mental Health Plan was developed, all reference to human rights had disappeared (Rees 2003, p. 34).

There has been some criticism of the effectiveness of the Rights Analysis Instrument as a measuring tool (Rees, 2003; Carney, 2003; Freckleton & Loff 1998). On the basis of the results of the Rights Analysis Instrument review, some commentators suggest that mental health legislation in all Australian States and Territories is now consistent with the UN Mental Health Principles (Whiteford & Buckingham, 2005; Whiteford et al. 2000; see also Rees, 2003). However, the stories related by consumers and practitioners during these consultations suggest that either the legislation is not yet consistent with the UN Mental Health Principles or that the legislation has not been effective in protecting consumers and carers against abuses.

In a recent critique of the capacity of mental health law and policy to respond to current and future challenges of community based care, Carney (2003) argues that while Australian legislation and policies may pass human rights scrutiny in principle, there is insufficient focus on the monitoring processes to ensure implementation and adherence to those measures (Carney, 2003, p. 12).

Since the Burdekin Report, there has been a more rapid move towards deinstitutionalisation and concurrently the rights of those who are still institutionalised seem to be better protected. However, the recent community consultations, and writings of academics, clearly suggest that it would be incorrect to assume that those advances have solved the multiple rights issues facing the mentally ill. While there is a lot to be said for preferring community treatment over institutional treatment, we cannot assume that community treatment is actually being effectively delivered. Just releasing mentally ill men, women and children into the community without appropriate supports is not an adequate reaction to the problems arising from institutionalisation.

In addition to the problems associated with institutionalisation in the early 1990’s, the Burdekin Report dealt with some of the deficiencies in community care. The stories heard during these consultations suggest that little has changed since then, other than the fact that there are increasing numbers of persons relying on that community care.

[A]nyone working within the public system today in any part of Australia or New Zealand (as well as in most Western countries) will be acutely aware of a range of problems in the post-deinstitutionalisation environment. Particular difficulties include the challenge of accessing inpatient care even in crisis situations; the heavy emphasis on pharmacological management of serious mental illnesses, generic case management leading to professional de-skilling, extensive use (over-use?) of compulsory treatment orders in the community; and inadequate resources allocation and staffing of mental health services. The result is arguably a sub-standard system of semi-institutionalisation within the community that lacks many of the best features of the old system. There cannot be said to be a true asylum for those with mental illnesses that need one. There is limited availability of effective multidisciplinary approaches to treatment, especially for those with comorbidities. It is dubious whether there can accurately be said to be appropriate protection from harm to self and others for people suffering acute effects of their mental illness. Stigma and lack of community understanding and support leave many suffers of mental health problems with poor quality of life, inadequate community supports, and reduced functionality and capacity to contribute to and enjoy life and work.

(Freckelton & Lesser, 2003, p. v)

Further, ten years after the first National Mental Health Plan, the key reviews of the outcomes (as opposed to the written policies) by government, independent authorities and non-government bodies suggest ongoing problems in accessing appropriate care.

…the clear message from the community is that people continue to experience problems in accessing services during crises and finding services that are responsive to their individual needs.

(Christopher Pyne, Parliamentary Secretary to the Minster for Health and Ageing, Foreword, National Mental Health Report 2004; Commonwealth Department of Health and Ageing, 2005)

The stories told during these consultations and surveys by mentally ill persons and their families suggest a pattern of continuing neglect. It seems that, even where there has been good policy or law, the policy has not been translated into reliable, high quality health care. Genuine empowerment of persons with illness and their families does not seem to have occurred at a local, regional or state level. The quality of life of those living with enduring illnesses in the community appears to be continually compromised by discontinuities of care, stigmatising community attitudes and overt and covert discriminatory practices in employment, education and social welfare.

State and territory governments have once again declared their commitment to continued reform. In the last 18 months most Health Ministers have recognised the long-standing neglect. However, while stand-out programs can be identified, there is no clear evidence of a systemic commitment to improved access to quality care. In fact, these consultations and other reviews of the mental health system suggest that we now have reached a point of serious and systemic neglect. Some governments have argued that they cannot keep up with increased demand and high expectations of good quality services.

Many of the major structural reforms proposed at the outset of the Strategy ten years ago have been followed through by all jurisdictions, and are near completion in some cases. The mental health service system is now faced with a different set of challenges, arising from both the new demands of community service delivery and growing awareness of the need for mental health care.

(National Mental Health Report 2004; Commonwealth Department of Health and Ageing, 2005, p. 30)

However, governments have been fully aware of the major gaps in services since at least the early 1990s. They agreed collectively in 1993, 1998 and 2003 (when each five-year mental health plan came into being) to correct basic system failures. Ignorance of the nature and the extent of the problem can no longer be used as an explanation.

It is apparent that the priority placed on resources for mental health has been decreasing, rather than increasing. Total health expenditure has increased rapidly over the last decade with Australian national health spending reaching 9.5% of GDP in 2003 ($72.2 billion, up from 8.4% in 1995-96). However, as a proportion of this expenditure, total mental health spending (excluding aged care), has remained static at less than 7% of recurrent funding (National Mental health Report 2004; Commonwealth Department of Health and Ageing, 2005).

...current funding levels in all states and territories may not be enough to meet priority community needs.

(National Mental Health Report 2004; Commonwealth Department of Health and Ageing, 2005, p. 18)

There is a fundamental inequity in health care expenditure allocation in Australia (Hickie et al. 2004). Generally speaking, expenditure on chronic or recurring illnesses like respiratory, nervous system and musculoskeletal diseases is greater than expenditure on health issues that create shorter term crises like cancer, cardiovascular episodes or accidents. The exception in this trend is expenditure on mental health. In other words, unlike the situation of those with physical illnesses, expenditure on our mental health care services does not meet the needs of the recurrent or chronically-disabling disorders that most people with a mental illness suffer. Rather the services cater to short-term and limited care.

The question of whether the existing service configuration is appropriate to meet the demand for services, or whether a different service configuration is required, remains fundamental.

(National Mental Health Report 2004; Commonwealth Department of Health and Ageing, 2005, p. 31)

These inequities in resource allocation and the failure to develop innovative and comprehensive services have major health and social consequences for those with mental illness and the wider community. For example, when persons who are ill cannot access appropriate health care they are more likely to become unemployed, homeless or enter into the criminal justice system.

Multiple and disjointed short-term solutions have been attempted over the last decade. Currently, the states and territories focus largely on improvements in the acute care and forensic areas with specific responses. However, without recognition that systemic inequities in resource allocation and service development exist, Australia is unlikely to develop the more comprehensive system of community-based care that offers the best chance of a high quality of life and protection of the basic rights for those persons whose lives are disrupted by mental illness.

2.1.3 HUMAN RIGHTS AND THE NATIONAL STANDARDS FOR MENTAL HEALTH SERVICES

Throughout this report, we have attempted to align the key themes expressed in the public meetings, individual consultations and written submissions with the National Standards for Mental Health Services that were agreed by all governments in the mid 1990s (Commonwealth Department of Health and Family Services, 1996).

While these standards are not a direct replica of the UN Mental Health Principles, they do reflect a basic commitment to provide services that respect individual human rights and equitable access to high quality mental health services.

The National Standards for Mental Health Services underpin a nationwide movement to implement appropriate community-based services and reflect our national commitment to provide 'the highest attainable standard’ of mental health care as required by ICESCR and the Convention on the Rights of the Child. As such, any genuine improvement in the provision of mental health services can be measured against these standards, and current failures in provision of services or respect for individual human rights amongst persons with mental illness are best understood against this background.

2.2 KEY THEMES FROM NATIONAL CONSULTATIONS AND WRITTEN SUBMISSIONS

The great majority of written and verbal submissions focused on deficits in key aspects of mental health care services. While a wider range of community and other welfare, housing and custodial services were the subject of individual or group submissions, the fundamental lack of access and failings in the access to quality health services available to persons with mental illness dominated the discourse. The contrast between experiences of care when presenting with a physical illness as compared to presenting with a mental illness was profound. A lack of respect for persons with mental illness or their families was commonly reported. The combination of a lack of respect, poor resources and inadequate facilities appeared to underpin the numerous reports of reduced safety within mental health care services. Pleas for the provision of basic care with dignity were almost universal.

A fundamental difference in perspective was evident between those who used services at a local or district level and those who administered services. Those who use services have grown tired and frustrated by presenting their individual stories to a long line of independent national or state-based reviews and inquiries. They feel exploited by the process and repeatedly traumatised. Many are frankly cynical about the process and do not feel that reporting their experiences now is likely to result in genuine government or professional responses. Nevertheless they did share their experiences with us.

Consumers and their family and carers prioritised a number of fundamental aspects of health care and related services – and these were generally consistent with other independent notions of quality of health care services (see Picker Institute Europe (http://www.pickereurope.org). These included:

1. access to professional care, particularly in emergency and other acute care settings;
2. treatment with dignity and concern for the individual irrespective of location of care;
3. prioritisation of safe and high quality services;
4. an emphasis on clinical care, rather than ‘containment' of those with mental disorders;
5. earliest possible access to professional care in acute and non-acute circumstances;
6. response to individual needs, including recognition of the complexity of comorbid substance abuse, personality dysfunction or socio-economic deprivation;
7. coordination of health, welfare and related community support services;
8. access to programs and support to live independently and work;
9. respect for the legitimate interests of family and carers in accessing care and participation in ongoing treatment decisions;
10. support for those who provide direct clinical services;
11. provision of appropriate community housing options; and
12. access to appropriate medical as well as psychological services.

After 4 January 2002 when our daughter had been transferred from the MHU [Mental Health Unit] into medical ward 2East, she was immediately treated by the staff as a whole person with dignity, respect, compassion and empathy. We observed that the medical ward staff was a professional caring team at all times, even when our daughter was a handful. They accepted the challenge with care, diligence, resourcefulness and a great team effort which achieved a great result in a short time in comparison with the five weeks that our daughter was in the MHU where she deteriorated badly. As parents, we are grateful for the clear concise and accurate information the medical ward team offered us, keeping us informed and assured that our daughter’s medical treatment was on-track.

(Carers, Parents, New South Wales, Submission #106)

I have to wonder if it were a serious physical illness or aliment if medical personnel would allow an individual to go unmediated for such a long period of time.

(Anonymous, Queensland, Submission #82)

People with mental illness are not receiving the same care as those with physical illnesses. There is inequity in funding for mental health projects.

(St Bartholomew’s House Inc, Western Australia, Submission #37)

In Esperance we have had no psychiatrist for 5 months. If consumers need acute care they have to be taken to a GP and then tranquilised and strapped to stretcher to be transported to Perth. I was told when I was suicidal, to drive myself to the city.

(Consumer, Western Australia, Perth Forum #45)

Why on earth are consumers who are exhibiting signs of a relapse not taken seriously? Why is it that the consumer needs to be either psychotic, suicidal, or in some other emergency before they are seen and treated?

(Carer, Husband, Western Australia, Submission #146)

We need a clinic we can walk into just like a 24 hr clinic you would attend for the flu. Why can’t we have it? Why do I need to self harm myself to receive relief? Why do I need to overdose to receive attention? Do I and many, many more need to die before we attend to what we preach that mental illness is like a physical illness?

(Consumer, Victoria, Submission #202)

Although St Bartholomew’s House continues to try and provide a quality service in supported accommodation (SAAP), the lack of resources, a staff ratio of 1:54, poor education of staff and the numbers of people requiring care limits the capacity to delivering safe quality care.

(St Bartholomew’s House, Western Australia, Submission #37)

Our son had done no wrong and as a mentally ill person deserved to be treated with dignity, care and understanding not to be confronted by police.

(Carer, Father, Western Australia, Submission #175)

I had an incident a while ago when I went to hospital in Bunbury, I was put aside (waited) a couple of hours – I wanted to go home but the hospital wouldn’t let me go. I finally went home and a few hours later the police came to take me back to the hospital. I went willingly and saw the doctor who said I needed an injection. I was threatened that the police would hold me down while I had the injection so I agreed to have it. After they injected me I was taken to Graylands Hospital in Perth but nobody informed my family of my admission to Graylands.

(Consumer, Western Australia, Bunbury Forum #1)

For me this is not strong language, during the ten years I have been a carer of a severely physically disabled mentally ill person, I feel I have been treated less then human, and the person I care for, as well as others with disabilities, looked upon as worthless citizens who the governments wished didn’t exist. Our loved ones are offered inferior care, if care is what it can be called.

(Carer, Husband, Northern Territory, Submission #68)

When a patient needs assistance, the Ambulance usually will not transport and the caller is directed to phone the police. Police will transport the client to the hospital in the back of a police wagon. This is a very degrading experience!

(Supported Accommodation Service Provider, Northern Territory, Submission #217)

Because intervention comes so late, consumers and families report that once the police are involved and no matter how the police are, there is still a sense of not being treated with dignity. One consumer explained the situation: “I know when I get sick that I quickly lose insight and will resist treatment but I am sick and there I am being handcuffed by police. No other groups of people with an illness are treated like this. Why are we? Surely there can be a better way. I think it starts with me being able to say, I’m becoming unwell and clinicians taking me seriously.”

(Mental Health Community Coalition Consumer and Carer Caucus, Australian Capital Territory, Submission #342)

By contrast, those who planned or administered services were perceived by consumers, carers and clinicians (evidenced by presentations at forums and in written submissions) to be preoccupied by:

1. the location of care services rather than the actual provision of care;
2. the cost-efficiency of different models of care;
3. managing down rather than responding to the increased demand for better quality services;
4. avoiding direct accountability for specific service failures and failures to invest in new services;
5. planning without consultation with staff, services, consumers and carers;
6. negating an emphasis on enhanced community care in favour of acute and custodial care; and,
7. rejecting legitimate critiques of the current systems of acute and community care.

Staff confidence in senior management involved in the redevelopment is at an all time low due to their refusal to listen to grass roots workers, consumers and carers. Front line continue to be pressured to provide more with less, services are fragmented, Staff are burning out, and positions are vacant for long periods due to the appalling pressure and conditions.

(Anonymous, Tasmania, Submission #254)

Despite the successes in making the changes outlined in the chapter on ‘Changes Made’ there are still unacceptable practices to be addressed. The outcomes though commendable do not represent ‘best practice’ or indeed in many cases even ‘good practice’.

(Eamon Shanley, Professor of Mental Health Nursing, Western Australia, Submission #33)

Those who are conscious of the practical and economic problems in providing care to over half the population at some point and up to a quarter within a 12 month period, have argued that a diagnosis should be associated with substantial functional disability before treatment should be funded and accessed (Regier et al 1998, Spitzer et al 1998). This is superficially attractive, however it means that people are required to become functionally disabled by their symptoms before they can be offered help. Such disability is usually hard to reverse even when treatment is effective…Restricting access in this way is antithetical to preventive and early intervention approaches, would be completely unacceptable in general medical care where people with mild disorders, such as a viral illness, can gain ready access, and may prevent the most cost-effective phase of serious illness from being treated. Mild disorders should be able to access treatment of some kind for all these reasons (Kessler 2003).

(Patrick McGorry, Professor of Psychiatry, Victoria, Submission #180)

Deinstitutionalisation has not failed. What has failed is the political will to fund essential support services in the community. The existing services are overwhelmed by the heavy demand they currently face and they are not able to provide the level of care and support required to assist recovery. This lack of support options dramatically increases the hardships faced by people who have a mental illness and their families, in terms of their health and their budgets. Ultimately, it is a failure of systems which is making people sick and forcing them into the costly acute care sector.

(Anglicare Tasmania, ‘Thin Ice: Living with Serious Mental Illness and Poverty in Tasmania’, Tasmania Submission #144)

There is an increasing number of people accessing mental health services which dilutes the quality of existing services – so with the quality of existing services being poor already you can see we are heading for a disaster.

(Clinician, Victoria, Morwell Forum #4)

The ability of Mental Health Services to deliver quality care has been severely restricted by continual budget cuts and the lack of funding to community services.

(Anonymous, Tasmania, Submission #254)

I would like to know why mental health funding is dominated by the medical model when funding could be better used to develop mechanisms to provide assistance for when people are well. We need to give people an opportunity of a life worth living. In the ACT less than 5% of the funding for health goes into social programs to help people do what they want to do with their lives. People’s expectations are so low…The medical model is about risk management. We neglect people when we leave them out to rot – in front of a TV all day! I lost all my social skills – I see so many of my fellow consumers who can’t do this because they have been dominated by the medical model. People go into self-medication with pills and drugs – we are now the dominant group in the criminal justice system. We need case workers who have no more than 8-10 clients and who can give due attention to people’s long-term needs.

(Consumer and Consumer Activist, Victoria, Footscray Forum #3)

I feel the inpatient unit in Bunbury provides a second-rate service to the mentally ill in the region as it does not provide a multi-disciplinary team. The Therapy Department went from 4 Full Time Employees, providing a day-service to clients for six-weeks intensive therapy to prevent hospital admissions, to now only 1.5 FTE, providing only an abbreviated day program to the current inpatients. The therapy department is now housed in the nursing station of the High Dependency Unit, due to the Community Staff moving into their space when they lost their premises. The patients have lost their group room, which now houses community staff, desks and computers. The whole APU is an overcrowded situation with the community staff moving into the small premises.

(Clinician, Western Australia, Submission #55)

We found that the therapeutic situation in the MHU [Mental Health Unit] is unacceptable in its overall treatment of people with mental illness…We found that the management of the MHU raises issues of delinquency or malpractice, whether by inadvertence, incompetence or deliberation. We observed the MHU staff working under considerable pressure, their services being under-resourced and their numbers inadequate for their patients’ safety. We are hesitant to single out particular staff, but we believe that individually it is their responsibility to practice appropriate duty of care and nursing similar to that demanded in hospital medical wards.

(Carers, Parents, New South Wales, Submission #106)

On a personal level, working in the APU [Acute Psychiatric Unit] provides a lot of anxiety for me at times. I feel there is no commitment by the hospital to provide a high standard of care for the mentally ill, funding is lacking, and the issue of safety, being an expensive one, does not hold high priority for the hospital or the current government.

(Clinician, Western Australia, Submission #55)

A constant catch-cry in feedback is the lack of community services. Failure to provide adequate community services perpetuates a revolving door outcome for the acute sector. There are numerous studies which demonstrate that well-structured community and support services are cost-saving to the health system in the long term.

(Mental Illness Fellowship of Australia, National, Submission #331)

What is needed are PROPERLY RESOURCED community based services which provide social and emotional supports, peer support and advocacy - which return to people their humanity, their dignity, their self-respect. (author’s emphasis)

(Consumer Advocate, NSW Submission #153)

Only a fraction even of the most seriously mentally ill can gain secure tenure in this system. So even with a system heavily targeted to chronic schizophrenia, only a minority even of these cases gain appropriate coverage. The rest are referred back to unsupported GP’s after the latest patch-up job otherwise called “episode of care”.

(Patrick McGorry, Professor of Psychiatry, Victoria, Submission #180)

Just because it is becoming more common to relocate such community-based services in Emergency Departments and elsewhere on acute hospital sites, doesn’t imply that this is the most effective deployment at all. This retreat to a “fortress” hospital mentality is ostensibly due to administrative staff OH&S concerns. However it is really due to Health Executives’ “land hunger”, plus the perceived need to make shortsighted attempts to assuage general hospital clinical pressures, eclipsing the real need for community based services which prioritise the best possible outcomes for service users and their families.

(Clinician, New South Wales, Submission #351)

There is a good reason for us to have a better community focus. Services at the moment are focused internally which is located in the hospital. To the Broken Hill people it may seem like just another hospital service.

(Clinician, New South Wales, Broken Hill Forum #9)

2.2.1 THEMES RELATING TO THE NATIONAL GOVERNMENT, NATIONAL MENTAL HEALTH STRATEGY AND NATIONAL RECOMMENDATIONS

The National Mental Health Strategy was developed over a decade ago to respond to obvious service failures and human rights concerns. An analysis of the current manifestations of that Strategy, namely the 2004 National Mental Health Report and the 2003-2008 Third National Mental Health Plan, suggest that we do not yet have a national process for translating the policy rhetoric into real increases in resources, enhanced service access, accepted service standards or service accountability.

Submissions and presentations at forums make it clear that neither those who use nor those who provide services have any faith in the continuation of the current national processes. The submissions suggest that key issues such as: national implementation of early intervention strategies; coordination of national alcohol, drug, mental health and suicide prevention strategies; implementation and ongoing review of national mental health standards; enhanced access to public and private sector mental health services (particularly for those who live in rural and regional areas); introduction of national measures of quality and safety; improved clinical care for the aged; support for innovation, research and sustainable new systems; and prioritisation of supported employment and rehabilitation services will not be realised by the current governments employing conventional bureaucratic processes.

Submissions and presentations at forums highlighted issues which need specific attention at the national level. These included:

1. poor access to psychiatrists, particularly outside major metropolitan centres;
2. poor access to psychologists, due to general lack of government or private insurance rebates;
3. lack of appropriate workplace-based rehabilitation and recovery programs;
4. declines in bulk-billing among general practitioners and psychiatrists over the past decade resulting in greater out-of-pocket expenses;
5. difficulties in accessing private health insurance cover;
6. limited access to new medications in outpatient settings, especially restrictions on the provision of PBS scripts;
7. major difficulties in personal dealings with Centrelink and other Federal welfare and support agencies; and
8. major difficulties with restricted access to the Disability Support Pension (DSP), Carer Allowance or other related welfare and health benefits.

The Burdekin report stated that “restriction to access to psychologists results in important treatment options being denied to many individuals affected by mental illness and that the lack of access is incompatible with human rights and is economically unsound”. It seems immoral that in 2004 clinical psychologists are not routinely available to people suffering mental disorders.

(ARAFMI Tasmania, Tasmania, Submission #245)

There’s only a visiting psychiatrist for this area. They come one day a week. We need more access than that. But then the problem in Adelaide if you can get up there is that there’s very little bulk billing 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. There’s not even a social worker here now, no OT now, no psychologists after several years. It’s all left to the mental health nurses who are expected to carry the load.

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

There are no services available for the 25 to 55-year age range beyond employment programs, whose existence and quality are inconsistent across the region.

(Anonymous, Northern Territory, Submission #271)

Consumers in the community are left dry. They are put out into their flat and that’s the end of it. The services we have are good but they lack staff resources and skill development. Some consumers are never given the opportunity to have rehabilitation.

(Carer, Mother, Northern Territory, Alice Springs Forum #13)

There is no supported employment program that meets the criteria of best overseas practice. My son would dearly love to work part-time, but in a field in which he has experience.

(Mental Health Community Coalition Consumer and Carer Caucus, Australian Capital Territory, Submission #342)

Australia is poorly served with employment programs for people with a mental illness and associated psychiatric disability. Traditional vocational rehabilitation services are far less effective than supported employment. As an example successful employment programs Trieste in northern Italy report an employment rate of 60% of people with schizophrenia whereas in Australia over 75% of people with schizophrenia are not working and on a disability pension.

(Mental Illness Fellowship of Australia, National, Submission #331)

People experiencing mental illness as well as their families frequently experience financial problems. For the people with the illness themselves, the longer they are sick or the more episodes they experience the more likely it is that their only income is Centrelink payments. It is very difficult to subsist on Centrelink payments. A Centrelink payment barely covers board or rent and people are often left with little for food, transport, clothing and other necessities. People with mental illness frequently have difficulty in affording health care and medications as well.

(Mental Health Community Coalition Consumer and Carer Caucus, Australian Capital Territory, Submission #342)

The following issues are of grave concern to us…A significant number of same-day hospital based psychiatry services require a co-payment to be met by the consumer, as the full cover of the services are not met by certain levels of cover offered by private health insurance funds. This effectively limits access to those services. If these co-payments increase, then some consumers will have to consider the option of dropping their private health insurance cover thus placing more strain on the public system.

(The National Network for Private Psychiatric Sector Consumers and Carers, National, Submission #225)

The following issues are of grave concern to us…The new atypical anti-psychotic medications should be available to consumers who suffer a mental illness, apart from schizophrenia. There is strong evidence that these medications can be used in low doses to very usefully to treat other disorders, particularly mood disorders. Currently, psychiatrists working in the public hospital system are able to prescribe these medications for disorders other than schizophrenia. However, psychiatrists in private practice are not, which effectively prohibits them from providing evidence-based best practice for many of their patients.

(The National Network for Private Psychiatric Sector Consumers and Carers, National, Submission #225)

2.2.2 KEY NATIONAL THEMES THAT EMERGE FROM REVIEW OF THE SERVICE ENVIRONMENTS WITHIN EACH OF THE STATES AND TERRITORIES

Review of the services within each State and Territory highlighted many common themes that fall within the responsibility of State and Territory governments. These included:

1. the scramble for acute care beds within each State;
2. restriction of access to acute care by exclusion on the basis of diagnosis (e.g. personality disorder, drug-related mental health problem) rather than clinical need;
3. premature discharge of unwell persons who remain at risk from inpatient and other acute care facilities;
4. difficulties accessing professional care during onset and to prevent deterioration of illness;
5. lack of access to medium or long-term care facilities, institutionally or community-based;
6. lack of coordinated and genuine youth-based or early intervention services;
7. lack of rehabilitation or recovery services;
8. poor state of forensic mental health services;
9. poor and dangerous processes for transfer of mental health patients to clinical facilities;
10. inappropriate use of ‘privacy' and ‘confidentiality' considerations to exclude families and carers from treatment planning;
11. lack of support for local clinical governance models, service innovation and local community partnerships;
12. over-reliance on crude service access or risk checklists, service protocols and other arbitrary non-clinical tools to regulate local service characteristics; and
13. lack of genuine and transparent data mechanisms pertaining to assessment of ongoing safety and quality of services.

I work with young people aged 13-18 years, but this is getting pushed out to work with people as old as 25. I provided 24 hour support to a 21 year old recently who couldn’t get care anywhere.

(Service Provider, Australian Capital Territory, Canberra Forum #20)

Parents have difficulty accessing limited child psychiatrists and psychologists for their disturbed youngsters. Adult facilities are inappropriate, overburdened and inaccessible. Early intervention and accurate diagnosis, stressed as priorities in the National Mental Health Plan 2003 – 2008, remain as rhetoric instead of reality.

(ARAFMI Tasmania, Tasmania, Submission #245)

The psychiatrist that was here before was great with feedback to other services and families – now the situation is hopeless. There are two of us (school counsellors) covering 8,000 people in this area. There is no child psychiatrist in the area and the service knew for about 12 months that he was leaving. Nothing has been done that I can see to replace him.

(Clinician, Western Australia, Bunbury Forum #8)

Young people’s mental health services are the most difficult to access. Often they are told they are not sick enough and then told they can’t get care because they have a comorbid drug and alcohol problem.

(Clinician, Queensland, Brisbane Forum #7)

No access to a spectrum of intervention, including whole of life span target groups. Anangu living on the NPY Lands have access only to a small range of acute mental health services whose responses are crisis driven and in circumstances where their involvement is most likely to be involuntary.

(Anonymous, Northern Territory, Submission #271)

People with personality disorders and those who self harm are treated with contempt and a lack of understanding particularly by unit staff. There is little or no expertise in working with people with this disorder.

(Anonymous, Queensland, Submission #113)

But there’s nowhere to go when you get out of Flynn. There’s no step-up or step-down care.

(Consumer and Consumer Consultant, Victoria, Morwell Forum #5)

It seems to me clear that staff were over anxious to discharge [X] due to the perennial shortage of beds at Mandala and that this is one of many cases which highlight Government neglect in the area of mental health facilities. Many promises are made but many do not eventuate or are delayed excessively. This is causing needless deaths in the community. The mental health beds at Wyong hospital have been promised for some time but are still not available. The public are entitled to expect that the mentally ill will be properly cared for by government funded services…The standard of care provided for [X] left much to be desired. After considerable questioning, this was reluctantly conceded by some of the doctors who gave evidence at this inquest…[X] was discharged with a minimum of formality and no guidance or assistance… (excerpt from the coroner’s report) [Suicide occurred in December 2002, 10 hours after being discharged from the Mandala Psychiatric Unit on the Central Coast. He made 2 suicide attempts prior to admission. [X] was released from the unit after 36 hours in the hospital.]

(Carers, Parents, New South Wales, Submission #137)

What is acceptable about refusing to carry out early intervention until the person is 'acutely' unwell, which leads to a very distressing forceful intervention, then having to administer extremely strong dosages of medication which induce obvious physical side effects which take months to subside?…What is acceptable about not keeping people with a mental illness as well as they can possibly be, thus reaching and maintaining their full potential within the illness?

(Carer, Mother, Victoria, Submission #178)

Andrews has attempted to calculate how much of the burden associated with psychiatric disorders is avertable with modern evidence-based treatments (Andrews 2000). While it seems clear he has underestimated this for schizophrenia (Goldberg 2003, Warner 2003), his general conclusions seem to be that much of this burden, up to 40% on average across a range of disorders is potentially avertable. If evidence based treatment were made available and coverage were increased we could avert nearly 30% of the burden in contrast to the present 13%.

(Patrick McGorry, Professor of Psychiatry, Victoria, Submission #180)

2.3 NATIONAL SURVEY OF MENTAL HEALTH PRIORITIES IMPLEMENTATION

This national survey conducted by the Mental Health Council of Australia, with support from the Brain and Mind Research Institute, University of Sydney, (as of 2 November 2004) resulted in 714 completed responses. The majority of respondents described their role within the mental health sector as public providers of specialist treatment (n=246, 34%). This was followed by consumers and carers (n=162, 22%) and then non-government community service providers (n=74, 10%).

For the top five community priorities for national mental health reform (that were identified earlier by community surveying during the development of ‘Out of Hospital, Out of Mind!’ [2003]), evidence of implementation at a local service level was extremely low. National rates for high level or full implementation of each of the priorities were:

• 17% for implementation of early intervention services;
• 11% for development of innovative services for those with comorbid substance abuse;
• 12% for development of a wider spectrum of acute and community-based care systems;
• 15% for implementation of the national standards for mental health services; and
• 9% for programs that promote attitudinal changes among health workers.

Importantly, these top priorities are not new, some were agreed targets of the previous national mental heath plan (1998-2003) – such as implementation of the National Standards for Mental Health Services, and all should be at the forefront of national and state/territory expenditure lists. They relate to the fundamental aspects of delivery of specialised mental health services in this country.

When respondents were then asked to rate other priorities that required implementation at a broader state/territory level, the low levels of national endorsement of high level or full support for implementation were equally disappointing. Worth highlighting were the low rates of:

• 13% for development of specific intergovernmental service agreements;
• 10% for innovation, research and service evaluation;
• 10% for introduction of specific schemes to enhance access to specialists;
• 11% for support of non-government agencies; and
• 11% for mechanisms for clear accountability of mental health strategy funds.

Finally, respondents living or working in rural, regional, remote or poorly resourced areas were asked about the extent to which service development was being supported in these areas. The national endorsement rates for high level or full support were so low (7% for rural and regional areas, 2% for poorly resourced areas) as to suggest a lack of basic interest or commitment by all governments to the development of new services in this high need areas.

2.4 NATIONAL SURVEY OF CONSUMER AND CARER EXPERIENCES OF CARE

Much of the work of the national mental health reform process in Australia has focused on moving the locus of care from institutions to the community-settings. By contrast, little work has actually focused on whether the experiences of care by those who use services have been enhanced by this process. What work has been done has tended to draw mostly from critical incident reviews rather than everyday experiences of care.

This novel survey mechanism introduced through the Mental Health Council in 2004, seeks to record ongoing experiences of care by those who actually use mental health services. It extends a framework initially developed in other areas of heath care to measure the quality of services provided (Hickie et al 2003 Australasian Psychiatry). It is in marked contrast to the mechanisms currently used or even proposed by the responsible governments. It relies on actual experiences of care and is not simply limited to critical incident reporting or ad hoc surveys of consumer participation or satisfaction with services.

As of 2 November 2004, 228 complete surveys had been received, including 127 (56%) from consumers, 58 from carers (25%) and 43 (19%) from family members or close friends. All respondents had experience (either direct or indirect) with mental health services during the previous twelve months. Forty-one percent (n=94) had contact with public health services, 30% (n=69) with private health services, and the remaining 29% (n=65) a mixture of the two.

With regard to key results from the survey, only 57% of respondents said that they were treated with respect and dignity always or nearly always, 69% felt that they did not have adequate access to services and 20% said that they were not able to find a health professional to talk to about their concerns. Two out of five (41%) participants felt they were given insufficient or no information about the condition or treatment. Of those respondents who wanted information given to family and friends, nearly 60% felt that not enough information was given. In situations where medication was prescribed for the mental health problem, only 24% responded that the purpose, benefits and side-effects were fully explained. Over one third (39%) did not feel they had enough say in decisions about care and treatment, and 19% had not had the diagnosis discussed with them (17% of consumers, 10% of carers and 37% of family members or close friends). Only five consumers (6%) had received a care plan, which is a document that outlines mental health needs and who will provide services. About one third (33%) of consumers rated the healthcare received in the last 12 months as poor to very poor, 30% as fair to good, and 37% as very good to excellent.

The Mental Health Council is committed to continuing this process of active review of individual experiences of care. It is not yet clear whether or not the responsible governments in Australia, or any of those other bodies who share responsibility for the provision of services, are also committed to this goal. However, current proposed Key Performance Indicators for Public Mental Health Services (National Mental Health Strategy 2003-08) do not include regular measures of consumer or carer outcome, or safety, nor do they propose such innovative measures of experiences of care.

2.5 NATIONAL MENTAL HEALTH REPORT 2004

The biennial National Mental Health Report has been the principal mechanism by which governments participating in the National Mental Health Strategy report their progress. It is based on primary data submitted by the States and Territories and the Commonwealth, which is then independently analysed. The focus of the report is largely on inputs and process variables, rather than actual services delivered or the quality or safety of those services. As the most recent report was released in November 2004 (detailing changes in expenditures up to mid 2002), it provides the most comprehensive national picture of the current state of mental health expenditures and service organisation.

The National Report (2004) indicates that the growth in government mental health spending (64.9%) has only just outpaced the growth in overall health expenditure (61.1%) indicating no real change in the overall pattern of health expenditure. National spending on specialised mental health services still only accounts for 6.4% of total gross recurrent expenditure on health care, even though mental illness accounts for over 13% of total health burden, or over 15% if the additional burden due to suicide and self-inflicted injury are included. While Commonwealth Government spending increased 128% during this period, two-thirds of that growth was due to new pharmaceuticals. State government spending increased only 40% or 26.2% in per capita terms. There continued to be wide variations between the States in terms of expenditure, service mix and implementation of quality and safety procedures.

The significant disparity that existed between jurisdictions at the commencement of the strategy largely remained nine years later… Differences in spending between the states and territories point to wide variation in the level of mental health services available to their populations.

(National Mental Health Report 2004; Commonwealth Department of Health and Ageing, p. 3)

The National Report highlights the change in allocation of spending from hospital-based to community-based services since 1992-93, with the latter now accounting for 51% of funds (up from 29%) and accompanied by a 109% increase in the number of clinical staff providing ambulatory mental health care. The support for non-government service providers has grown from 2% to 5.5% of expenditure, though varying from 1.9% in South Australia to 9.3% in Victoria. However, as the report highlights, much of the change is accounted for largely by radical changes within one State, namely Victoria. NSW had already instituted such changes largely before the Strategy commenced and some other States such as South Australia have still not moved away from their reliance largely on institutional services.

The number of beds in stand alone psychiatric hospitals has fallen by 60%, largely due to reduction in the non-acute service sector with these beds having been reduced by 53%. The number of beds located in general hospitals increased by 65% with the overall number of acute beds in the system therefore remaining largely static (approx. 3,700 beds, unchanged since 1993) and despite the increased growth in the population and demand for services since that time. Actual total public sector inpatient beds per 100,000 fell from 45.5 to 30.4 from June 1993 to June 2002, a staggering 33% decrease during a period of increased demand for services. For all inpatient services, there was a 26% reduction in total beds and a 11% reduction in clinical staff.

All states and territories have experienced increased demand for mental health care right across the health sector, and in particular for inpatient care.

(National Mental Health Report 2004; Commonwealth Department of Health and Ageing, p. 7)

Over the same period, changes in use of outpatient medical services funded by the Commonwealth peaked in the mid to late 1990s and have been declining since. Although there are more registered providers of these services, they are increasingly working part-time. The disparity between rural and regional services provided and urban areas is great (Burgess Report).

Major disparities continue to exist between the states and territories in the level and mix of psychiatric beds provided to their populations…The number of beds required to treat and care for people affected by mental illness is also a function of whether alternative community based services are available.

(National Mental Health Report 2004; Commonwealth Department of Health and Ageing, p. 7)

The move away from institutional services was designed both to improve the spectrum of care services available as well as provide a more cost-efficient model. However, it seems that the movement away from a hospital base has meant that hospital-based services are now in short supply. Further, community-services and related workforces have not expanded sufficiently to meet the increased demand and the relative needs for increased expenditure on mental health seem to have lost out to the other traditional hospital-based and procedural areas of medicine (Hickie et al. submitted).

…these indicators (comparative per capita staff employed in ambulatory care) provide a simplified view of the relative progress by states and territories…they do not tell us about the ambulatory care workforce required to meet priority community needs nor the amount of care actually provided.

(National Mental Health Report 2004; Commonwealth Department of Health and Ageing, p. 21)

While the participation by mental health consumers in formal representation within mental health organisations has grown from 33% to 77% since 1992-93, actual participation rates in key processes (e.g. complaints review, 57%) are substantially lower. For carer participation, the rates are even lower (e.g. 48% for complaints review). From a quality and safety perspective, only 49% of public mental health systems had completed reviews under the National Standards by the previously agreed finishing date of June 2003.

Concerns about poor service quality were a major factor leading to the development of the National Mental Health Policy in 1992… Much of the previous and current criticism of mental health services concerns its alleged failures in these areas.

(National Mental Health Report 2004; Commonwealth Department of Health and Ageing, p. 32)

2.6 SUMMARY OF AUSTRALIAN PROGRESS AGAINST WORLD HEALTH ORGANISATIONS (WHO) RECOMMENDATIONS (2001) FOR MENTAL HEALTH REFORM IN BETTER RESOURCED COUNTRIES

TABLE 2.6.1: Progress on actions required for the improvement of mental healthcare in developed countries with a high level of resources (e.g. Australia) based on overall recommendations made by WHO (World Health Organization, 2001, Table 5.1, p. 114).

RECOMMENDATION	ACTION	NOTES ON PROGRESS IN AUSTRALIA
1. Mental health treatment to be provided in primary care	Effective management of mental disorders in primary care to be improved	Although significant primary care developments are now supported by the Australian Government, major barriers still exist with regards to access to appropriate non-pharmacological therapies. This is particularly the case for those treated in primary care environments. Consequently, there is over reliance on medications and under utilisation of effective psychological strategies (Hickie et al. 2001).
	Patterns of referral to be improved	Access to mental health specialists is inequitable in Australia and is contributed to largely by lower socio-economic status and significant distances between major population centres (Burgess et al. 2002).
2. Psychotropic drugs to be made available	Easier access to be provided to newer psychotropic drugs (under public or private treatment plans)	While Australia 's PBS system does offer equitable access to most medicines at low cost to the consumer, differences do arise between availability of new compounds for inpatients versus outpatients. Specifically, over the last five years, submissions indicated that access to some of the newer antipsychotic agents has been effectively limited to those receiving care or through the public hospital sector.
3. Care to be given in the community	Remaining custodial mental hospitals to be closed down	Considerable progress has been made with regard to closure of stand alone or custodial hospitals (National Mental Health Report 2004). However, some very large institutions remain, most notably Glenside Hospital in South Australia .
	Alternative residential facilities to be developed	Submissions indicated that development of alternative residential or community-based long-stay facilities has not been prioritised and remains a major gap in the services structure.
	Community care facilities to be provided (100% coverage)	Submissions noted that while community-based treatment services are universal in their coverage, access to emergency care or effective ongoing care through such facilities is limited.
	Individualised care to be given in the community to people with serious mental disorders	Case-management systems have been the standard mode of care, emphasising individual treatment plans. However, submissions challenged whether the quality and effectiveness of such plans is ever audited.
4. The public needs to be educated	Public campaigns to be launched for the recognition and treatment of common mental disorders	The Australian Government in association with lead states such as Victoria established beyondblue: the national depression initiative. Some major states, notably NSW and WA, declined participation in the national program with adverse effects for their constituents (Jorm et al. 2005). Other schools-based programs such as MindMatters make a significant contribution (Waring 2000).
5. Communities, families and consumers to be involved	Advocacy initiatives to be fostered	The Mental Health Council of Australia was established and supported by the Australian Government to represent views to the Minister. It incorporates the views of consumers and families, and includes provider and other non-government organisations. Australian Government also provides support to other national consumer networks.
	Support for other specific consumer, carer or community advocacy agencies, particularly at a state and local level has been more episodic (National Mental Health Report 2004).
6. National policies, programmes and legislation need to be established	Fairness in healthcare financing (including insurance) to be ensured	Medicare related systems have underpinned equity in individual health care access for those with mental disorders. However, submissions indicate that more recent developments in private health insurance now pose a serious threat to these principles. At a population level, mental health is not resourced appropriately relative to its disease burden or the availability of effective treatments (Hickie et al. 2004).
7. Human resources need to be developed	Specialists to be trained in advanced treatment skills	Currently, services provided by psychiatrists in the private sector are in decline (National Mental Health Report 2004). In some States difficulties now exist with regard to recruitment to specialist psychiatrist training (e.g. NSW in 2005). Psychiatrists working in the public sector report increased dissatisfaction with their roles (Rey et al. 2004)
		Submissions indicated that there is a major workforce shortage in mental health nursing and that specialist psychologists are relatively underutilised in the Australian health care system.
8. Other sectors need to be linked	Special facilities to be provided in schools and the workplace for people with mental disorders	While increased mental health literacy programs are now promoted to some schools and in some workplaces, actual access to care is not mandatory.
	Evidence-based mental health promotion programmes to be initiated in collaboration with other sectors	Mental health promotion has been supported in Australia , but the reach and intensity of programs is limited in reach and duration.
9. Community mental health needs to be monitored	Advanced mental health monitoring systems to be developed	Mental Health Information systems, particularly with regard to tracking experiences of care in individual persons, are in their infancy in Australia . Submissions highlighted that basic issues of service and the maintenance of quality and safety have received inadequate attention.
	Preventive programmes to be monitored for effectiveness	Where new preventative programs have been established, evaluation has been accepted as an intrinsic component (Hickie 2002, 2004).
10. More research needs to be supported	Research on the causes of mental disorders to be extended	National expenditure on basic and clinical research is low by developed world standards (Hickie et al. 2004).
	Research on service delivery to be carried out	Health services research is poorly supported by current mechanisms (Jorm et al. 2002).
	Evidence on the prevention of mental disorders to be investigated	Significant preventative trials have been supported directly and indirectly by the Australian Government and NMHRC. (Hickie 2002)

Note: “Actions” accompanying each recommendation for countries with low and medium levels of resources for mental healthcare are described in the original report.

2.7 STATE / TERRITORY BASED SUMMARIES

While many common issues were presented across the country, there were also significant differences in various states and territories.

The following text attempts to summarise some of those differences and their implications as derived from data obtained from the consultations and submissions, the MHCA surveys and the 2004 National Mental Health Report. However for a fuller consideration of the mental health care system in each state and territory please refer to the full report.

a) From the National Mental Health Report 2004

The National Mental Health Report shows that state/territory differences have decreased marginally between 1993 and 2002 but this has been insufficient to lift services to a comparable level across jurisdictions. Comparisons between the jurisdictions has therefore failed to lift spending in most states that were lowest on the table in 1993. A more effective response would be to assess the level of funding required to meet community needs. While measurement of jurisdictional funding levels should be secondary to measurement of consumer service levels, in the absence of such data, we are restricted to comparing expenditure levels, staff numbers and bed numbers.

The better performers:

• Western Australia leads per capita spending - $110.82 (national average of $92.03) and has improved from fourth position in 1992-93.
• Western Australia reports the highest number of clinical staff working in ambulatory mental health services (42.9/100,000).
• Victoria reports the highest percentage of expenditure to non-government organisations (9.3%) and has the best developed psychiatric rehabilitation services.
• Tasmania reports the highest number of total inpatient and 24 hour staffed residential beds (51.0/100,000) and the highest number of clinical service delivery staff (104.0/100,000).
• Victoria reports the most dramatic growth in expenditure on community and general hospital services ($291.2 million) and the most dramatic reduction on spending in stand alone facilities ($180.5 million).

The poorer performers:

• Of the bottom four states and territories ( NSW , NT , ACT and QLD) in 1992-93, New South Wales had the lowest per capita percentage growth over the next decade (23.0% in NSW compared with 36.9%, 38.3% and 41.8% in the others respectively).
• Queensland reports the lowest number of clinical staff working in ambulatory mental health services (29.8/100,000).
• South Australia reports the lowest percentage of expenditure to non-government organisations (1.9%).
• The Northern Territory reports the lowest number of total inpatient and 24 hour staffed residential beds (16.2/100,000), while of the states, New South Wales reports the lowest at 34.0/100,000. Similarly, the NT has the lowest number of clinical staff (78.1/100,000) while NSW is almost as bad (81.2/100,000).
• South Australia reports no reduction in expenditure on stand alone psychiatric facilities and only a modest growth in expenditure on community and general hospital facilities ($37.8 million). South Australia has the highest proportion of psychiatric beds still in stand alone facilities (73%).

b) From the MHCA Surveys

The MHCA surveys discussed in Part 3 of the main report suggest the following:

The better performers:

• Perceived implementation of national mental health priorities is somewhat better in Victoria and the Australian Capital Territory .
• Victoria demonstrates the greatest commitment to mental health promotion, destigmatisation and illness prevention.
• Victoria houses the most innovative service development systems in youth and early intervention services.

The poorer performers:

• Perceived implementation of the national priorities in mental health is poor in South Australia and New South Wales .

c) From the Public Consultations and Written Submissions received

The written and oral submissions made by consumers, advocates, mental health professionals and others suggest the following:

The better performers:

• Victoria is perceived to be the national home for service development for early intervention for persons in the initial stages of psychosis or other severe mental disorders.
• Victoria is perceived to be at the forefront of community-based initiatives to improve understanding of depression, anxiety and other common mental disorders.
• Victoria has implemented a new service specifically for persons with severe personality disorders.
• Victoria has the standout forensic mental health institutions.
• South Australia has an impressive magistrates court diversion program.
• Tasmania is perceived to be in the process of significant increases in resource allocation.

The poorer performers:

• New South Wales has the highest degree of demoralisation and dissatisfaction among mental health clinicians, consumers and carers.
• New South Wales and Queensland are perceived to have a high emphasis on a ‘law and order' rather than enhanced clinical care approach.
• New South Wales is perceived to be backing an institutional and emergency care focus at the expense of community service development.
• South Australia is perceived to have made little genuine commitment to support persons with mental illness to live effectively in the community.
• Western Australia is perceived to have made few efforts to deal with the problems faced by regional and remote communities.

d) State and territory perspectives

As Part 1 of this report sets out, each State and Territory was provided a draft of this report for comment. The full text of those responses can be found at Appendix 8.2 of the main report.

2.7.1 NEW SOUTH WALES

2.7.1.1 Overview

The deficiencies in mental health services in NSW continue to attract widespread media and community attention (see Appendix 8.7). In December 2002, after a comprehensive analysis of the current state and delivery of mental health services, the Hon Dr Brian Pezzutti, the Chair of the Legislative Council Select Committee on Mental Health stated:

The objectives of the Richmond Report and the deinstitutionalisation process have been undermined by practical problems arising during implementation. Consequently, NSW has a community mental health sector with a large responsibility for mental health care, but not the necessary resources. The weight of evidence presented to the Committee highlights that mental health services in NSW need revolutionary improvement. Deinstitutionalisation, without adequate community care, has resulted in a new form of institutionalisation: homelessness and imprisonment. (p. xv)

The Select Committee not only highlighted inadequacy of funding but also raised concerns about the model of resource allocation and the accountability of funds once disbursed. Implementation of State policy at an Area Health Service level was cited as a serious problem. Additionally, with regard to the Burdekin Report, the Select Committee stated:

The Burdekin Report identified not only inefficient planning and organisational arrangements to integrate services within hospitals, but also a lack of procedures to involve families in the community treatment process. It was considered that these issues had not been adequately addressed. Evidence received by this Select Committee indicates that in NSW these issues still require further attention. (p. 13)

The Pezzutti inquiry led to a number of specific State Government responses. In December 2003 the NSW Mental Health Sentinel Events Review Committee reported on its systematic review of suicides and homicides amongst mental health patients. It stated:

Such events are an unmitigated tragedy for the victims, their families and their friends, and also result in great distress to the staff of mental health services and to other patients. The fear and concern they raise in the community is significant, and is largely responsible for the continuing and unjustified stigmatisation of the vast majority of people suffering from mental illness who pose no risk except to themselves. (p. v)

(NSW Mental Health Sentinel Events Review Committee (2003). Tracking tragedy: A systemic look at suicides and homicides amongst mental health inpatients. First report of the Committee, December 2003)

More specifically, the report acknowledged that many people with mental illness are not able to access care in times of crisis:

Admission to mental health beds is widely seen as the most effective short-term risk mitigation strategy in high risk cases. However, anecdotal evidence strongly suggests that on occasions patients are not being admitted, or are being discharged early or without comprehensive follow up, due to an inability to access an available inpatient bed. (p. v)

The report also highlighted concerns with regard to assessment procedures, communication and documentation practices, lack of family involvement, staffing issues and non-uniform implementation of NSW Health policies and guidelines which may “act to impede the efficient provision of a standardised approach to care delivery”. (p. ix)

(NSW Mental Health Sentinel Events Review Committee (2003). Tracking Tragedy: A systemic look at suicides and homicides amongst mental health inpatients. First report of the Committee, December 2003)

The release Tracking Tragedy attracted community criticism as some of its recommendations emphasised increased security and further restriction of patient’s rights within acute hospital settings rather than enhanced clinical care (Sydney Morning Herald, Jan 2004). A major alliance of non-government organisations and professional groups wrote to the Premier in early 2004 to express their lack of confidence in the provision of mental health services in NSW. Ongoing media criticism was high and coronial reports continued to highlight major service deficiencies, particularly for young people with severe disorders.

The NSW Health Minister responded positively and met with community stakeholders and professional groups. In mid 2004 the State Government announced that an additional $241 million would be spent on mental health over the next four years. Further, it prioritised the development of new forensic mental health services, announcing its intention to build a new forensic hospital on the existing Long Bay Gaol site.

The subsequent release of the National Mental Health Report (NMHR, November 2004), indicated, however, that there had been little improvement in NSW’s comparative position over the last decade (the NMHR 2004 is based on 2001-2 data). Key indicators included overall expenditure (now ranked sixth out of eight states and territories), low bed availability and limited employment of new community-based staff. NSW now faces serious manpower shortages across all clinical disciplines.

Issues raised by the formal submissions and the community forums included the Government’s failure to respond positively to workforce demoralisation, its dismissal of clinicians’ objections to the introduction and utility of the new clinical outcomes documentation and that its failure to integrate clinical and academic leadership with local service innovation or clinical service development. The fierce criticisms by professional groups of the central administration of public mental health services were consistent with an independent survey of practicing psychiatrists reported in 2004 (Walter and Rey, 2004).

The future capacity of NSW to attract high quality staff to meet basic service requirements may well be compromised by a lack of attention to basic clinical leadership, clinical governance and clinical career development issues. It appears that central and local bureaucracies demand greater reporting by clinical staff without providing the support or space for local clinical innovation, clinical leadership or resources for significant local service initiatives. In 2005, NSW instigated an urgent review of the training of psychiatrists in the state. (Medical Training and Education Council of NSW (MTEC), 2005)

While NSW has supported the development of a specialist mood disorders research Institute (Black Dog Institute. Available at: http://www.blackdoginstitute.org.au), it remains the only state not participating in the national depression initiative: beyondblue. Additionally it has been under-represented in the early take-up of new general practice-based and federally-funded access to allied mental health practitioner programs (Hickie et al, 2004). The building of a new forensic hospital on an existing corrective services site does not suggest that expansion of clinical care and reduction of the stigma associated with severe mental illness is a high government priority.

While substantial new financial commitments have been made for the period 2005-09, the accumulated deficit in recurrent funding is large and there seems to be a preference towards funding acute hospital and forensic services. The emphasis on building new Psychiatric Emergency Care Centres (PECC) in Emergency Departments may lead to a re-segregation of persons with mental disorders from persons with other physical health emergencies. One major driver to this process is the poor quality of acute care provided to persons with mental illness. However, it is possible that the belief of at least some emergency room clinicians that persons with mental illness are “interfering with” or “detracting from” the acute care of other patients may also be influencing this new trend.

The relationship between poor ongoing community care and increasing demand for acute care services and the relative failure to partner effectively with consumers and carers, general practice and other non-government service providers does not appear to have yet received serious attention. Data from NSW indicates a continuing rise in the number of acute admissions to psychiatric facilities and an increasing proportion of admissions occurring on an involuntary basis.

Even though there were positive accounts of the success of court diversion programs in NSW, there were many more stories that spoke scathingly about the increased focus on security in NSW. The perception remains that the main State’s for people with a mental illness is overly focused on incarceration or detention rather than expansion of non-custodial clinical care. There is no doubt that the increasing presence of security staff, rather than health professionals such as nurses and psychologists, within acute care facilities reinforces this perception.

The introduction of a transparent and efficient system for monitoring and reporting not just the quantity but the quality of services provided, with a specific emphasis on deaths and critical incidents among those seeking or receiving mental health care, remains a priority. Consumers and carers remain unconvinced that there is any serious interest in monitoring either routine experiences of care or implementing changes evident from these critical incident reviews.

The release of Tracking Tragedy 2004 (the second report of the NSW Mental Health Sentinel Events Review Committee) in March 2005 also highlights areas of concern regarding access to services. This Report was a systematic review of homicide by mental health patients and suicide death of patients recently discharged from mental health inpatient units over a five-year period (1999-2003). The Committee concluded:

Overall the group data provided some evidence for a link between reduced access to inpatient care and higher rates of post-discharge suicide death. Area Health Services with lower numbers of mental health beds relative to their estimated population-based bed requirements had higher rates of post-discharge suicide death. People dying by suicide within one month of discharge had a shorter length of stay than the overall population of people being discharged from mental health services, and in particular, a higher number of short (2-3 day) admissions. In Individual cases inappropriately short length of stay may have contributed to the poor outcome.

(NSW Mental Health Sentinel Events Review Committee, 2005, p. viii)

On 11 March 2005, the Government released another new blueprint for mental health services in NSW (The NSW Government’s Plan for Mental Health Services) and re-announced its $241 million commitment to increased funding over a four year period. The new Plan commits the Government to opening 240 new mental health beds in the next three years, expansion of the PECCs from two to five hospitals, introduction of new electronic medical record systems, and expansion of the Housing Support Accommodation Initiative (HASI) to a further 460 people in public and community housing. The documentation claims that the increased expenditure will lift NSW’s per capita spending by $14.30.

In May 2005, the NSW Auditor-General released a report on the performance of Emergency Mental Health Services (Auditor-General’s Report, Performance Audit, Emergency Mental Health Services, May 2005). The report states the following view:

The increase in demand for emergency mental health services has offset many (and perhaps all) of the gains from funding increases. The system is under considerable pressure, and patients can face lengthy delays before being admitted to a bed.

There is a continuing cycle over the past few years of adverse reports, followed by announcements by the government to address the mental health care system, followed by further reports indicateing little change. This is cause for a fundamentally different approach, consistent with the recommendations in this report, to tackling the systemic issues evident in the NSW mental health services.

2.7.1.2 Key issues raised by consultations and submissions

The major issues highlighted by the consultations and formal submissions in NSW were:

1. the apparent emphasis on a ‘law and order' agenda rather than enhanced clinical care;
2. the emphasis on enhanced security measures within acute care settings, with increased use of security rather than clinical care staff;
3. continued and widespread difficulties in accessing acute care services, particularly outside business hours and through emergency departments of general hospitals;
4. a critical lack of mental health beds including not only acute care beds but also medium term services;
5. lack of support for community-based acute and ongoing clinical care;
6. lack of support for non-government service providers, particularly in employment support and rehabilitation services;
7. lack of support for genuine consumer and carer participation in planning, review and distribution of services;
8. workforce shortages across all disciplines leading to further demoralisation of the existing workforce;
9. inadequate and inappropriate forensic mental health services;
10. lack of accountability for mental health spending, service deficits and critical incidents in the mental health sector;
11. resentment at the manner of introduction of new outcome-based clinical measurement systems at the expense of enhancement of actual clinical services; and
12. poor coordination of inter-departmental responsibilities and most notably those that involved service provision and protection of children.

2.7.1.3 Positive developments

While the general level of distress expressed by NSW consumers, carers, non-government and professional bodies was among the highest nationwide, our attention was also drawn to a number of positive state-wide developments or local initiatives. These included:

1. statewide development of a forensic mental health service to be managed by Justice Health rather than the Department of Corrective Services;
2. the development of a statewide Court Liaison service in 2003/04 program for persons with mental disorders presenting to magistrate and district courts;
3. recent NSW commitments to support a new mind and neuroscience research strategy as well as a Professor of Schizophrenia-related research in association with NISAD;
4. very positive attitudes to mental health being expressed by police and emergency services, reflecting a major change in attitudes over the last decade;
5. development of a joint initiative between NSW Health, the NSW Department of Housing and other non-government organisations (HASI) to improve the community and housing supports for those with very high levels of disability; and
6. increased commitment by NSW Health to monitor systematically experiences of care by consumers and carers within its services and report publicly,

New South Wales: Court Diversion Programs

The diversion of individuals with mental health issues and/or intellectual disability is exemplified by recent changes to Section 32 of the Mental Health (Criminal Procedure) Act 1990. Courts are now able to divert individuals to treatment and able to enforce such orders by virtue to the individual being returned to court following notification by COS [Community Offender Services] of failure to comply with Section 32 treatment orders. These changes in legislation are a result of negotiation and agreement between COS, the Attorney General’s Department, NSW Health and the Department of Disability, Home Care and Ageing.

COS provide sentencers with a range of community-based sentencing options including Community Service Orders and the Intensive Supervision Program as alternatives to incarceration. However, both the Community Service Orders and the Intensive Supervision program require a degree of stability, including stable accommodation and appropriate intervention resources.

In order to meet the conditions of the order and the offending needs of the individual, COS both develops and delivers core programs and brokers a range of services from government and non-government agencies that are funded to provide services within the community. Major partners in the provision of services and programs to offenders with complex needs are the Department of Housing, NSW Health (Community Mental Health and Community Health), the Department of Ageing, Disability and Home Care, the Department of Education, Employment and Training and Centrelink.

(Community Offender Services, Probation and Parole Service, Department of Corrective Services, New South Wales, Submission #317)

Housing and Support Initiative

The Housing and Supported Accommodation Initiative (HASI) aims to strengthen the partnership with Housing and NGO's in delivering accommodation support to people with mental illness to live successfully in the community. The initiative is underpinned by policy, by statewide tender programs to ensure standard levels of care and by evaluation and review mechanisms. The development of the HASI program for NSW will be a staged process:

•  Stage One – 118 Medium to High Support places in the community

NSW Health is funding $5m/year recurrently to mental health non-government organisations (NGOs) for high-level accommodation support.

The DOH has provided housing stock of approximately $7.8m.

Preliminary outcomes in the South Eastern Sydney trial over a twelve month period show that inpatient beds days for enrolled patients decreased from 197 days to 32 days.

•  Stage Two - 460 Low outreach support places to people in public and community housing

NSW Health is funding $15m over 4 years to mental health NGO's for low-level disability outreach support for people with mental illness and disability associated with that illness already living in community and public housing.

•  Stage Three - 126 places in medium to high support

The 2005/2006 mental health budget announced on 24 May 2005 has allocated an additional $8 million for NGOs to provide moderate to high-level accommodation support. Housing will fund stock component. These places will be allocated across all Area Health Services. This program is due to go to Statewide tender processes within the next two months for the NGO support component.

…(after 3 years) the Government will be providing support to an additional 700 people with a mental illness to live a quality life in the community, not hospital.

(Media Release 24 May 2005 and supporting information from the office of theNSW Minister for Health, Hon. Morris Iemma.)

2.7.1.4 National Mental Health Report (NMHR) 2004 (analysis of expenditure and services)

According to the NMHR 2004, NSW finishes sixth out of the eight states and territories in terms of per capita expenditure ($85.13), and remains well below the national average ($92.03). It was ranked fifth in 1992-93 at the start of the national strategy. Over the last decade, mental health spending has increased 23% in per capita terms with the national state average being 26.2%. Only Victoria reporting a lower per capita increase (14.2%). In NSW, there has been a considerable growth in community and general hospital services ($170.9m, compared with the highest, Victoria, at $291.2m), but only a modest reduction in spending on stand alone institutions (a $35m reduction compared with Victoria’s reduction of $180.5m).

In terms of clinical staff employed in ambulatory care settings it ranks sixth (35.2/100,000 population compared with national average of 35.9 and a high of 42.9 in Western Australia). With regard to clinical care staff, NSW ranks seventh (81.2/100,000) only outperforming the Northern Territory (78.1) and below the national average of 90.0 and the high of 104.0 in Tasmania. NSW ranks seventh in terms of funding to non-government organisations (2.4% of mental health funding compared with national average of 5.5% and the highest being in Victoria at 9.3%). NSW ranks sixth in terms of total inpatient and 24 hour staffed residential beds per 100,000 population (34.0 compared with the highest nationally of 51.0 in Tasmania). Total public sector inpatient beds in NSW ranked fifth in the Commonwealth (30.3/100,000).

2.7.1.5 Mental Health Council Survey Reports

As expected, the largest number of responses to the survey were from NSW organisations and individuals (n=239). There remains a low level of perceived support for or actual implementation of the community’s top five priorities for mental health reform at a local level (namely early intervention [15%], innovative services for comorbid substance abuse [10%], wider spectrum of acute and community care [11%], implementation of the national mental health standards [14%], programs to support attitudinal change [8%]). With regard to state-wide initiatives, again there was a very low level of perceived support for or implementation of key initiatives (namely, specific inter-governmental service agreements [13%], support for innovation [8%], enhanced access [12%], clear accountability for funds [12%]).

2.7.1.6 Conclusions

NSW is faced with the dual difficulties of a combination of an extended period of low per capita expenditure on mental health and low confidence among clinicians about its capacity to bring about rapid improvements. Additionally, there appears to be a focus on expansion of old models of acute and hospital-based services rather than genuine service innovation or new partnerships with non-government or primary care service providers.

2.7.2 VICTORIA

2.7.2.1 Overview

The deficiencies in the provision of mental health services in Victoria have continued to attract widespread media and community attention, with a particular focus on deficits in acute and emergency care. Deficiencies in acute care services were highlighted by a report of the Victorian Auditor-General (2002) Mental Health Services for People in Crisis.

This audit identifies a range of concerns about the timeliness of service provision, the completion of key service delivery processes in compliance with relevant standards and guidelines, and the burdens placed upon carers and families. In making these findings, I do not wish to impugn the many dedicated professionals providing mental health services. It is clear that the service system is under significant stress, due to demand pressure, work force shortages and the increasing complexity of mental disorder in our society.

(J. W. Cameron, Auditor-General, 14, p. vii)

The negative impact of poor mental health on consumers, their families and the wider community was also cited in the Victorian Auditor-General’s Report (2002) as was the higher rate of unemployment, substance abuse, physical illness and social dislocation amongst people with mental disorder. These problems have also been identified in each of the three National Mental Health Plans.

This audit sought to examine mental health services for people in crisis and found:

Increasing service demand and associated levels of unmet demand are resulting in service access difficulties for many consumers, early discharge from hospital, and increased burden on family and carers. These outcomes increase the likelihood of future unplanned re-admissions.

(Victorian Auditor-General's Report, 2002;, p 6)

Many recommendations were made regarding assessment procedures, documentation, timeliness and appropriateness of service responses to crises, discharge practices, integrated care, involvement of carers and families, rights of involuntary patients and evaluation of the effectiveness of mental health services. The Auditor-General noted that many of the recommendations arising from this audit were promptly recognised and incorporated in the new five-year plan for the delivery of public mental health services New Directions for Victoria’s Mental Health Services: The Next Five Years (2002).

The stated underlying guide of the New Directions for Victoria’s Mental Health Services: The Next Five Years (2002) is Victoria’s whole-of-government social policy framework Growing Victoria Together. This approach puts the plan in an ideal position to deal with the associated health, social and economic ramifications experienced by many people with mental illness and their families and carers. The New Directions five-year plan identified the following key areas as the focus of reform over this period:

1. manage the growing demand for mental health services;

2. respond to increasingly complex consumer needs — particularly the needs associated with increasing drug use amongst young people with mental illness;

3. develop improved responses to consumer and carer needs, including developing new models of care - particularly for people with high needs;

4. establish and maintain an appropriate balance between inpatient and community-based services;

5. address workforce challenges, including education, training, recruitment and retention; and

6. ensure the future sustainability of services.

(New Directions for Victoria 's Mental Health Services: The Next Five Years, 2002, p.5)

Resource distribution, both between inpatient and community based care and allocation to rural and regional areas, and the benefits of focussing on early intervention to reduce demand on acute care and negative impacts on consumers were also addressed. Many short- and long-term initiatives were outlined in this plan to redress gaps in service provision.

Two recent reports also outline initiatives to redress gaps in the provision of mental health services and protection of the rights of people with mental illness: Victoria’s Implementation of the National Standards for Mental Heath Services: Progress Report (September 2004) and the Annual Report 2003 Office of the Chief Psychiatrist (November 2004). However, both documents failed to self-identify areas of concern and disappointingly, no attempt was made to benchmark progress against the implementation of the National Standards for Mental Health Services (NSMHS). However, under each of the eleven NSMHS, lists were presented (not against specific criteria) describing some current and possible future initiatives. The list for Standard 11 (Delivery of Care), the most detailed of all the Standards, was minimal.

Victoria has seen considerable mental health promotion and prevention development under the independent auspices of VIC HEALTH and the recent commitment to establish a research centre devoted to this task. It has also led the development of the national depression initiative: beyondblue (which is now supported by the Australian Government for a further four years to June 2009) and has been one of the active participants in the new general practice-based and federally-funded access to allied mental health practitioner programs.

It has been at the forefront of Australian developments in institutional forensic mental health services through the establishment of Forensicare at the Thomas Embling Hospital. Academic clinical service and basic neuroscience research developments, particularly related to psychosis, have been of international standing. The establishment of Orygen Youth Health through community and service partnerships has been a major development. However, the internationally-leading work of Professor McGorry and colleagues with regard to early intervention in young persons with psychosis (recognised by an NHMRC Program Grant 2005-2009) has not yet been implemented substantially throughout the state.

In Australia the requirement for entrenched disability or life-threatening risk operates at a high threshold at the entry points to specialist care. Primary care access is theoretically better, however practically still a problem. Generally, treatment for milder disorders and earlier phases of disorder is provided through little better than a lottery system in which affluence and local factors are key influences. Such people are often derided as the “worried well” even within psychiatry. They may not need years of treatment but they do have a right of access to appropriate treatment. Why not acknowledge that ready access to mental health care of some kind, much of it relatively simple, even informal and self-care, is as necessary as access to general medical care? This should not be controversial.

(Patrick McGorry, Professor of Psychiatry, Victoria , Submission #180)

Since the commencement of the National Mental Health Strategy in 1993, Victoria is the state that has undertaken the most systematic reforms consistent with the spirit of that strategy. That is, it has drastically reduced its reliance on beds in stand alone psychiatry hospitals with a significant move to new beds in general hospitals, other community-based beds and support for longer-term services provided by non-government organisations (Vic Auditor-General’s Report 2002; New Directions Report 2002). It has also fared well in amending legislation to protect many rights of people with mental illness (Watchirs 2000, Carney 2003).

At a macro-level, therefore, it is easy to comprehend the direction of service reform. However, it is also clear that expenditure growth has not backed this process of systematic reform and that there is considerable variation in quality of services provided across the state. Gaps in service provision are common. Medical staff shortages in rural and regional areas are being filled largely with overseas trained doctors. Access to private sector services is strongly tied to inner and eastern Melbourne. The main focus of care in Victoria still appears to be on acute care and the protection of rights of involuntary patients rather than early intervention and protection of the broader rights to social, economic and political participation of people with mental illness and mental health problems. The impact of inadequate mental health services in emergency departments has been particularly emphasised by both health professionals and users of the services.

The recent announcement of the Victorian Strategy for safety and quality in public mental health services 2004-2008 by the Victorian Department of Human Services heralds a major breakthrough for the improvement of safety and quality of practice in the delivery of mental health services. To date, the inclusion of mental health within broader health, safety and quality assurance programs have failed at both state and national levels. This new initiative should assist with the identification of systemic problems and issues of accountability. Victoria’s commitment to the rights of people with mental illness is also evidenced by the recent release of Patient Rights Booklets in twelve languages in December 2004.

Just prior to the release of this report, Victoria announced a new mental health package value at approximately $180 million over four years, with approximately $55 million devoted to capital works and $125 million in recurrent spending over four years. Just over $30 million per year is an approximate increase of 5% in recurrent spending. Increases in funding were announced to acute community-based assessment teams, support for assessments in emergency departments and for facilities that can function as alternatives to acute hospitalisation.

2.7.2.2 Key issues raised by consultations and submissions

The major issues highlighted by the consultations and formal submissions in Victoria were:

1. continued and widespread difficulties in accessing acute care services, particularly through emergency departments of general hospitals;
2. a critical lack of mental health beds, including not only acute care beds but also medium term services;
3. lack of support for community-based acute and ongoing clinical care;
4. inadequate rural and regional services, with a strong emphasis on providing minimal intervention services; and
5. lack of accountability for mental health spending, service deficits and critical incidents in the mental health sector.

Although the mental health system in Victoria is more appealing at a macro level than many of the other state-based services, the general level of distress expressed by Victorian consumers, carers, and non-government and professional bodies was still very high. Critical incidents and day-to-day service failures were not perceived to be given sufficient priority by government and professional bodies.

2.7.2.3 Positive developments

Our attention, was drawn to a number of positive state-wide developments or local initiatives. These included:

1. the Orygen Youth mental health services providing early interventions for young people with psychosis;
2. institutional forensic mental health services, and in particular the Thomas Embling Hospital services which are of a high inte