Chapter 2 - Mental health - The case for change
This committee is neither the first to inquire into Australia's
mental health services, nor the first to find them wanting. When the Human
Rights and Equal Opportunity Commission (HREOC) conducted an inquiry into human
rights and mental illness (generally known as the Burdekin Report) in the early
1990s, it found serious problems in the area of mental health. The Commission
In general, the savings resulting from deinstitutionalisation
have not been redirected to mental health services in the community. These
remain seriously underfunded, as do the non-government organisations which
struggle to support consumers and their carers...Poor inter-sectoral links, the
ambivalent stance of the private sector and a reluctance on the part of
government agencies to co-operate in the delivery of services to people with
mental illness have contributed to the alarming situation described in this
report. While the Inquiry welcomes the initiative recently taken by governments
in endorsing a National Mental Health
Policy and Plan, a major
injection of resources will be needed before we are in a position to comply
with our international obligations under the UN Principles for the Protection
of Persons with Mental Illness.
In the time that it took Burdekin and the HREOC to
conduct that inquiry, federal, state and territory governments cooperated to
produce the National Mental Health Strategy.
Signed off by governments in 1992, the aims of this strategy are to:
Promote the mental health of the Australian community;
To, where possible, prevent the development of mental disorder;
Reduce the impact of mental disorders on individuals, families
and the community; and
Assure the rights of people with mental disorder.
The Final Report of the 1997 Evaluation of the first
National Mental Health Strategy indicated that when the National Mental Health
Strategy was first implemented in 1992, mental health services were 'in a poor
state'. However, while mental health
services had improved the evaluation recognised that the strategy had 'raised
awareness of previously hidden problem areas' and that much work remained to be
The 2003 evaluation of the Second National Mental
Health Plan was, if anything, less positive in outlook. While
recognising a range of achievements, it said:
However, the extent and pace of progress has not universally
been viewed as satisfactory. In particular, the national community
consultations reveal a high level of dissatisfaction. However, it should be
noted that progress has been constrained by the level of resources available
for mental health and by varying commitment to mental health care reform. While
the aims of the Second 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
Around that same time, the Mental Health Council of
Australia released its Out of Hospital,
Out of Mind! report. This was a collaborative effort of the Mental Health
Council of Australia, a national peak non-government organisation (NGO) for
consumers, carers, professional associations and health care providers, and the
Brain and Mind Research Institute. The report made a harsh judgement of the
results of reforms over the previous decade:
For over ten years, our national policy and government-driven
reform processes have championed the appropriate move to non-institutional
forms of care. The findings from this national and comprehensive consultation
are stark. The overwhelming perception of those who currently use or provide
services is that we have now arrived at a position of ‘OUT OF HOSPITAL, OUT OF
MIND!’. That is, one of the most chronically disadvantaged groups in this
country continues to be ignored. After two five-year National Mental Health
Plans this does not represent a failure of policy, but rather a failure of
implementation. This includes poor government administration and
accountability, lack of ongoing government commitment to genuine reform and
failure to support the degree of community development required to achieve high
quality mental health care outside institutions.
Two years later this was followed by a second
collaborative report Not for Service,
released on 19 October 2005,
which was similarly scathing about consumers' experiences in the mental health
system. It concluded that 'after 12 years of mental health reform in Australia,
any person seeking mental health care runs the serious risk that his or her
basic needs will be ignored, trivialised or neglected'.
Another major mental health NGO, SANE Australia,
produced an annual report on progress in mental health service provision and
stigma reduction. It was even more blunt in its assessment of the state of
mental health services:
Mental health services are in crisis to varying degrees all
barely able to cope with people experiencing acute episodes of illness, let
alone provide ongoing treatment and support...
The National Mental Health Strategy is in retreat on many
fronts, with old-style psychiatric institutions still in place, community-based
services being drawn back into hospitals, prison psychiatric units being built
instead of discrete forensic hospitals, and prisons becoming de facto
While there had been inquiries and strategies at the
national level, individual states and territories have also examined aspects of
mental health in their jurisdictions, with reports often preceding significant
policy initiatives. These inquiries have included:
In NSW, a Legislative Council Inquiry into Mental
In NSW, the NSW Auditor General's report on
emergency mental health services
In Victoria, the Victorian Auditor General's Inquiry
on Mental Health Services for People in Crisis
In the Northern Territory, the review of the NT
Department of Health and Community Services
In South Australia, the South Australian
Ombudsman's Inquiry into Treatment of Mental Health
In South Australia, a Legislative Council Select
Committee Inquiry into Assessment and Treatment Services for People with Mental
In Western Australia, the review of the Mental Health Act 1996 and the Criminal Law (Mentally Impaired Defendants)
In Western Australia, a Legislative Council
Inquiry into Mental Health Services
In Tasmania, the Bridging The Gap Report, a review of mental health services in
Despite the many plans, and the progress made, analysis
of mental health in Australia
in the National Mental Health Report found
Since 1993, mental health has not increased its
shared of health spending
There remains a high level of need in the
community for mental health services
There is uneven expenditure on mental health between
and within states and territories, which is even more uneven when it comes to the
utilisation of NGOs
The reduction in stand-alone psychiatric
facilities (which was an objective of the National Mental Health Strategy) has taken
place alongside increased demand for mental health care, 'in particular, for
acute inpatient care', something regarded by consumers and carers as 'needing
Issues central to the inquiry
This committee heard an enormous range of evidence,
about many different issues. On some questions there was strong consensus, on
others there was vigorous disagreement. Many of the issues raised in the
reports and reviews outlined above remain critical and seriously in need of
There is an urgent need for more mental health services. Whatever debates there are about what
those services should be, there is consensus that at present there is simply
not enough mental health care. The point was often made that in no other sector
of health care would it be regarded as acceptable that 60 per cent of people
with needs received no service. Even more frequently it was pointed out that
the proportion of the health budget spent on mental health care bears no
relation to the proportion of the disease burden attributable to mental illness.
It is all very well to say, as some did, that there should not be a direct relativity
between those two indicators, but no
one has mounted a credible defence of the current level of spending. Given the
decades of under-spending in infrastructure, the mental health workforce and
services and the fact that mental illness causes a greater level of years lived
with disability than any other category of disease, it should surely be a
spending priority: if anything, it might be expected to get more than a proportionate
share of the budget. Instead, it has been suggested that 'it is likely that
overall mental health spending as a proportion of national health spending is
now actually declining'.
The limited resources
available are not always well utilised. The 'revolving door syndrome'
described by many witnesses suggests the current focus almost exclusively on
the most seriously ill is not working. Psychiatrists are scarce outside capital
cities. General practitioners (GPs) are more readily available but only a small
proportion have undertaken more than rudimentary
training in mental health. Clinical psychologists, however, are largely
excluded from Medicare rebate funded services, despite their capacity to
deliver evidence-based treatment particularly for high prevalence disorders.
Public psychiatric hospital beds are scarce, yet many
are occupied by people who should be treated by more suitable lower cost
services. While acute bed shortages are very common, the neglect of timely,
early stage intervention may be responsible for much of that acute demand.
Case workers typically have too many consumers, placing
strains on the quality of the attention they give.
The non-government sector has the potential to be more
than just a minor player as its role in some other countries shows. Consumers
are not sufficiently engaged in the design and delivery of services. Families,
carers and consumers are not always recognised, supported or even consulted.
has not been achieved. At worst, Australia
has shifted care for the seriously ill from stand-alone psychiatric
institutions to prisons. The rate of mental illness amongst inmates is unacceptably
high. Further, while beds in public stand-alone psychiatric hospitals have
shrunk, private ones have expanded, albeit offering services to people with
much less debilitating illnesses than those now being admitted to the public
system. The committee received little evidence to suggest that the incomplete form
of deinstitutionalisation practised in Australia
had improved health or welfare outcomes. Low levels of employment and high
rates of homelessness are just two of the indicators of failure, not of
deinstitutionalisation but of what was supposed to be the provision of at least
comparable mental health services in the community to which seriously ill
people had been released.
To be clear, the committee does not doubt the necessity
to end the century-old practice of locking people with mental illness away with
little expectation of recovery or reintegration into society.
has its limitations. Most acute care
beds are now provided in psychiatric wards of general hospitals. However
the environments of these wards can be less than therapeutic for seriously ill
people in disturbed states.
Mobile crisis teams set up in some states now typically
attend fewer crises, for under-resourcing and security related reasons, and are
more likely to be found in over-stretched accident and emergency departments of
general hospitals. The committee heard alarming accounts of the physical and
chemical restraint of patients due to lack of expertise in treating people with
mental illness, lack of acute psychiatric beds and the inappropriateness of
emergency department settings for those experiencing serious and psychotic
Community-based mental health centres in NSW, along
with their resources, are being mainstreamed onto sites in hospital grounds
despite the difficulty of accessing them and a reluctance to visit those
facilities by the many people whose previous experience in hospitals was
negative. The committee received little evidence that stigma was reduced
through this kind of mainstreaming.
There is inadequate
community-based care. Expansion of community-based services is supposed to
be part of mental health policy, but there has been a lack of funding and commitment
to this objective.
The National Mental Health
Strategy was developed in response to clear evidence that community-based
treatment has better health outcomes and less life disruption for the majority
of individuals with acute and long-term mental illness. The evidence also
suggests that brief admissions to acute psychiatric wards within general
hospitals backed up by ready access to 24 hour clinical services and a
well-staffed range of supported residential facilities in the community,
including in the person's home, is superior to hospital-centred care,
particularly that provided in stand-alone psychiatric facilities. The committee
notes that this approach is in line with the Australian National Mental
Health Service Standards but that no state or territory has
yet provided local community-based care in any comprehensive way.
The National Mental Health
Strategy aimed to not only shift services from institutions to local
communities but to recognise the right of people to live in the 'least
restrictive' circumstances and to develop strong links with groups of
consumers, families, GPs, the non-government sector and local services like
housing, general disability services, social security and employment.
People with mental illness are treated in some states
as outpatients in public area mental health services but, as with inpatient
beds, services are stretched and available only to the most unwell. Others, it
is expected, will be treated as private patients by GPs and psychiatrists. However,
shortages of doctors, particularly those willing and able to deal with often
complex psychiatric conditions and to bulk bill for their services, make this
an inadequate response. The ideal of publicly funded, integrated teams of
psychiatrists, psychologists and psychiatric nurses who can respond in a timely
fashion with accurate assessment and effective treatment of a wide range of
mental health conditions is missing. Lack of respite and rehabilitation beds,
discharge planning from hospital and clinical support in short and medium term
supported accommodation and work opportunities contribute to the expensive, revolving
door syndrome of repeat acute care admissions.
For the not-insignificant minority who are severely
disabled by their illness and need ongoing secure care, it is considered by the
committee that there should be adequate, spacious secure sites in the
environment of general hospitals where patients have access to a range of
rehabilitative services and general physical health care. These are in addition
to secure forensic facilities, which while different in some respects, should
also provide rehabilitative services and have the ability to ensure general
physical health care needs are met.
Prevention is definitely
better than cure. Everyone seems agreed on the value of raising awareness
of mental illness, of reducing stigma, and of prevention and early intervention
programs. Such initiatives are frequently cited as being both clinically
effective and less costly. However, it is not clear that funding is following
this clinical consensus. This type of program is being trialled, but there is
room for further expansion. However, data has already shown that many people
currently do not seek treatment for their illness, and there is little point
striving for reduction in the stigma and increased awareness, if people find
there is no support available when they take the first step toward getting
help. Stigma reduction and education campaigns will need to be matched with
growth in resources for treatment.
Quality of care appears to vary greatly from place to place. The availability of health care
professionals, particularly those other than GPs, plummets outside the capital
cities. Each state and territory has its services organised differently, and
the range in quality of treatment between jurisdictions surprised and at times
disturbed the committee. Some health care institutions have unacceptable
standards of care. The National Mental Health
Strategy appears not to have made any difference to marked differences in care
and treatment across a patchy and fragmented system. It was said that many states had still not
implemented the first National Mental Health Plan and were years behind leaders
such as Victoria
in service delivery. The response to criticisms and mental health crises by
many governments has been to fund pilot projects and offer short-term grants
for worthwhile programs. This work is
rarely evaluated or funded more universally.
illnesses receive more attention than others, in part as a result of the
focus on 'serious mental illness' in the National Mental Health
Strategy. Across the country, the
Committee heard about people with borderline personality disorder experiencing
discrimination and lack of effective treatment. Particular
conditions such as obsessive compulsive disorder, self harming, post-natal
depression and often fatal eating disorders lack specialised treatment support
and get lost in the current attention on psychotic mental illnesses.
are preventing effective care. This problem is most serious in the areas of
dual diagnosis and the justice system. People with drug or alcohol problems as
well as mental illness are shuffled between services unable and sometimes unwilling
to treat both conditions. Dual diagnosis is still not effectively addressed,
despite it being the expectation rather than the exception amongst people with
mental illness, particularly those ending up in the criminal justice system. Police
cells, courts and jails are filling with those experiencing mental illness, who
are getting inadequate treatment or none at all in environments that are
anything but therapeutic. Those in jail are frequently discharged with little
or no transitional support, increasing the chances of recidivism, not to
mention the cost of what is often a high level of seclusion and surveillance
afforded them in prison.
Some people get more mental health care than others.
The complex needs of asylum seekers, particularly if they are in immigration
detention, have not been adequately catered for, although the committee is
pleased by recent reforms in this area. Cases such as that of Cornelia Rau
highlight how some people, whether suspected illegal immigrants or the
homeless, are less likely to be considered as potentially having a mentally illness,
and less likely to receive proper diagnosis and treatment. Spending on mental
health in children and youth is not commensurate with prevalence or
opportunities for early intervention. There is also a significant divide between
rich and poor. People who are poor and/or do not have private health insurance
have fewer treatment options, and appear particularly unlikely to be able to
afford ongoing treatment for anxiety disorders or depression. Nowhere is this more evident than in
medical model is hampering improvement in mental health care. Psychiatry,
while central to the treatment of mental illness, by its own admission is not
always able to explain many of the causes and pathways of mental illness. The
Committee discerned much frustration among consumers and carers that, despite
the persistence of the mysteries of the mind, psychiatric responses often seem
rigid and unaccommodating of alternative approaches. Pharmaceutical treatments
are certainly improving but their use is also growing at extremely rapid rates,
as is Commonwealth expenditure under the Pharmaceutical Benefits Schedule yet
psychologists qualified to deliver evidence-based 'talking therapies' are
significantly under-utilised in publicly-funded mental health care. Australia
has very few psychotherapists and alternative therapies get short shrift,
despite some evidence of success. As in other fields of medicine, there must be
a move toward more multidisciplinary care approaches to health, and a move away
from the narrow medical model. There is a need to counter the effects of stigma
due to poor knowledge of appropriate interventions for mental illness among
health professionals, as well as among the public. Consumers are often
marginalised in the design and conduct of research and the evaluation of
These are some of the recurrent themes expressed by
many different groups and individuals as the committee travelled around the
country The experiences related to the committee,
and the facts set out for it, were depressingly similar to those presented in
the Burdekin Report ten years earlier. However, there has been progress as
Recent initiatives around the country
The harsh criticisms made by HREOC, the Mental Health Council
of Australia and others, and the limited progress documented in reports on
mental health services, are well founded. Nevertheless, there have also been
successful and substantial initiatives taken by
NGOs and by state, territory and federal governments in recent years.
The non-government sector has been responsible for
putting forward many good programs and ideas for combating mental illness. It
has been at the forefront of seeking to make the goals of the National Mental
Health Strategy a reality. Examples brought to the committee's
Partnerships in community-based care, bringing
clinical care together with accommodation and other services
Programs aimed at addressing interactions
between mental illness, drug dependency and homelessness
Mental illness awareness and education programs
Online support services for consumers or carers
A range of services in which consumers are
playing key roles
Training programs, such as mental health first
There are many government initiatives in the area of
mental health, discussed below, and in later chapters. Overall, the great
breadth of the goals in National Mental Health
Plans makes it difficult to assess the extent to which government initiatives
systematically address priority needs. New proposals seem patchy, not
consistent between jurisdictions, and sometimes lack sustainable funding
(discussed further in Chapter 4). With inadequate funding in the system as a
whole, and an overemphasis being placed on acute care, established programs may
well be valuable but limit expenditure in other worthy areas.
The Australian Government expressed its role in
addressing and managing mental health in Australia
as providing leadership on mental health issues at the national level and to fund
programs. This includes medical and
pharmaceutical benefits funding, the delivery of primary care services through GPs,
the provision of funding through the Australian Health Care Agreements, and
programs to support special needs groups. The Australian Government also
provides a range of other programs such as income support, social services and
housing assistance programs.
Since the launch of the National Mental
Health Strategy, recurrent government expenditure on mental
health from 1992-93 to 2002-03 has increased by 73 per cent (real terms).
The largest item of Commonwealth expenditure and area of fastest growth
has been the subsidising of medicines under the Pharmaceutical Benefits Scheme.
Commonwealth initiatives have included:
National standards for mental health services,
with a review of almost 50 per cent of all public service mental health
services completed and 40 per cent currently under review.
A national system of reporting on mental health
resources and services.
Introduction of new Medicare items through the Better Outcomes in Mental Health program
and mental health training funding for participating GPs.
Funding for consumers and carers to attend key
mental health conferences and forums.
A review of State and Territory-based
legislation to ensure consistency with United Nations Principles for the
Protection of Persons with Mental Illness and the Improvement of Mental
State and Territory Governments essentially deliver and
manage mental health services within their respective jurisdictions. Since the launch of the National Mental
Health Strategy, each jurisdiction has implemented reforms
and recent initiatives include:
Primary Mental Health
and Early Intervention Teams to assist primary health providers in the
recognition of mental illness at an early stage and provide specialist
$3.5 million provided on an annual basis to beyondblue, the NGO promoting community
awareness of depression, its treatment and prevention.
Funding for projects tracking population
attitudes (anti-discrimination, promotion of economic participation and social
inclusion for particular groups including refugees, young people, rural,
indigenous and older people) and research assessing the effectiveness of mental
health care initiatives.
Funding some newer pharmaceuticals not covered
under the Pharmaceutical Benefits Scheme.
$5 million to deliver psychiatric disability
rehabilitation and support services to assist people with mental illness, their
families and carers.
Development of the Queensland State Forensic Mental
Health Plan and Standards
and the creation of new mental health positions in associated areas.
'Implementation of the Voluntary Referral
Program for mental health.'
Launch of Project
300, to assist in rehabilitating people undergoing extended psychiatric
Inpatient beds redistributed into regional
centres and the Queensland Centre
for Rural and Remote Mental Health established
to deliver programs to people in regional areas.
Establishment of Crisis Intervention Teams
between the Queensland Police Service and health service agencies and Mental Health
Child Safety Support Teams.
Funding a post-graduate psychiatry program to
increase the number of specialist trainees across the State.
Enhanced interactions between mental health
service providers, consumers, carers and funding groups.
Significant capital works undertaken
to reform community services.
Implementation of 'routine collection of
consumer outcome measures' and training of mental health workers in using the
Territory Criminal Code (Mental Impairment and Unfitness to be Tried) Act 2002
amended to ensure offenders with a mental health illness are assessed and
treatment is available in the ‘least restrictive’ environment.
The Mental Health
and Substance Misuse Project commenced in 2004, bringing together mental health
providers with organisations treating substance abuse.
The new Primary Health Care Service was
established in Darwin to link mental health consumers with GPs in the
Revised policies and procedures have been
implemented for risk assessment, complaints management and provision of
information to consumers and carers.
Modifications to address safety issues in
inpatient facilities are complete, or nearing completion.
As part of the ACT's comprehensive forensic
mental health model, the Criminal Code
(Mental Impairment) Amendment Bill 2006 was introduced on 16 February
2006, clarifying definitions of mental impairment for offenders and alleged
$20 million to NGOs for mental health services
and non-clinical support, such as education, supported accommodation and
respite, and counselling.
Discharge planners in inpatient units to assist
in the transition of inpatients back into the community.
Additional mental health officer positions
across mental health care services.
Mobile Intensive Treatment Teams to support
consumers living in the community who have high level needs.
The MindMatters School Project to increase
awareness and understanding of mental health issues in schools and other
From 1 July 2005, a system to monitor the use of
seclusion and restraint of people with a mental illness.
New campaigns to increase the recruitment and
retention of specialist mental health staff.
The Integrated Services Project for Clients with
Challenging Behaviour pilot program to assist people with a mental illness with
long term housing support and care.
Mental Health – Clinical Care and Prevention
model released, estimating the number of people in age groups with mental
illness and linking the varying levels of severity with treatments required
from mental health care providers.
Funding to NGOs to deliver community services.
A range of initiatives addressing the needs of
people with both a mental illness and a substance abuse disorder.
Pilot programs specially targeting people with a
mental illness who are from culturally and linguistically diverse backgrounds.
Skilling the mental health care workforce
through training programs, including a Graduate Certificate in Mental Health
for General Practitioners.
Community Forensic Mental Health Service
established to provide consultation and case management.
An exposure draft of a new Mental
Health Bill for NSW (which was to be tabled in late 2005, but now expected in the first half of
'an Australian-first pilot program between
mental health services and ambulance services of specially trained crews of
mental health staff and ambulance paramedics who are available (initially only
in the northern and southern metropolitan areas) to attend call-outs to crisis
situations throughout the night'.
$25 million extra in grant monies for
non-government community health services in 2004/2005'.
A pilot project on 'Perinatal and Infant Mental
Health in the Community'.
Reforms in the area of supported accommodation.
A Memorandum of Understanding between the
Commonwealth (Department of Immigration and Multicultural Affairs) and the
State Government of SA (Department of Health) for health services to
A Magistrates Court Diversion Program and
planning for new forensic mental health facilities.
62 packages of care to support clients to live
in the community.
A 12 bed high support community facility in
12 bed cluster houses for supported
accommodation in the South and the North West Coast.
A total of 48 new clinical positions across a
range of mental health care settings.
$3.78m to drive quality and safety improvements,
assist with the application of the Mental Health
Act and develop a mother and baby service.
$4.52m to upgrade existing mental health and NGOs'
facilities and services.
Acceptance of recommendations and action to be
taken to reform Ward 1E at Launceston General Hospital, which had been the
subject of complaints.
The committee thus recognises that efforts are being
made in the area of mental health, indeed it sought examples of good practice
that are expanded upon elsewhere. It recognises, too, that there are some signs
that the pace of improvement is increasing. As Professor Ian Hickie recently
remarked, the ground is shifting rapidly, and 'finally...the situation has some
hope of genuinely changing'.
Nevertheless, the committee encountered a widespread
dissatisfaction with the state of service, and a strong consensus for the need
for further change. The view is widespread that more resources are needed in
mental health, but also that the way resources are used needs to change. Chapter
4 outlines how mental health is resourced and discusses how it might be
reformed. Later chapters tackle many questions surrounding how resources need
to be directed and what services need to be expanded. The conclusion to this
report discusses future directions for mental health in the context of the
National Mental Health Strategy.
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