Chapter 2 - Mental health - The case for change

Chapter 2 - Mental health - The case for change

2.1       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 concluded that:

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.[14]

2.2       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.[15]

2.3       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'.[16] 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 done.[17]

2.4       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 and commitment.[18]

2.5       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.[19]

2.6       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'.[20]

2.7       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 around Australia, 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 psychiatric institutions.[21]

2.8       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:

2.9       Despite the many plans, and the progress made, analysis of mental health in Australia in the National Mental Health Report found that:

Issues central to the inquiry

2.10      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 attention.

2.11      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,[32] 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'.[33]

2.12      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.

2.13      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.

2.14      Case workers typically have too many consumers, placing strains on the quality of the attention they give.

2.15      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.

2.16      Deinstitutionalisation 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.

2.17      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.

2.18      Mainstreaming 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.

2.19      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 episodes.

2.20      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.

2.21      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.

2.22      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.

2.23      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.

2.24      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.

2.25      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.

2.26      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.

2.27      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.

2.28      Some mental illnesses receive more attention than others, in part as a result of the focus on 'serious mental illness' in the National Mental Health Strategy.[34] 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.

2.29      Service silos 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.

2.30      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 Indigenous communities.

2.31      The dominant 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 treatments.

2.32      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 well.

Recent initiatives around the country

2.33      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.

2.34      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 attention include:

2.35      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.

2.36      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.[41] 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.

2.37      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).[42] 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:

2.38      State and Territory Governments essentially deliver and manage mental health services within their respective jurisdictions.[48] Since the launch of the National Mental Health Strategy, each jurisdiction has implemented reforms and recent initiatives include:

2.39      Victoria

2.40      Queensland

2.41      Western Australia

2.42      Northern Territory

2.43      ACT

2.44      NSW

2.45      South Australia

2.46      Tasmania

2.47      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'.[95]

2.48      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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