Out of Hospital, Out of Mind
In 1992, the Australian Health Ministers committed their governments to correct decades of neglect in mental health. A national mental health policy was developed and mechanisms were described to: lift Commonwealth and State expenditures; reduce human rights abuses; move the locus of care from hospitals to the community; and, deliver quality mental health within the mainstream of Australian health and welfare services.
In 1993, the Human Rights Commissioner’s Report (‘Burdekin Report’) brought the human rights issues of overt abuse within institutions, and covert neglect in the wider community, to the attention of the general public.
For the next 10 years, Australian governments implemented two five-year plans aimed at: facilitating genuine participation for consumers and carers; developing high quality community-based mental health care; and, outlining a broader population-based health promotion and disease prevention approach.
This new national focus, on a long-neglected health area, assumed that all governments would invest additional dollars in the exercise. Those persons in need of mental health services, and their families, greeted these national commitments with great enthusiasm and expectation. Everyone assumed that real change required not only large increases in resources but also promotion of genuine national leadership and widespread professional and community support.
THE 2002 MENTAL HEALTH COUNCIL REVIEW
After 10 years of this national approach, the Mental Health Council of Australia (MHCA) conducted a nationwide review to ask those who used, or provided, mental health care whether substantial change had been achieved. This national consultation involved over 400 organisations and individuals and was conducted between August and December 2002. It utilised appropriate qualitative and quantitative methodologies. The face-to-face consultations and the three-stage mailed surveys engaged a wide range of national bodies representing consumers and carers, professional groups, NGOs and local service providers.
The major conclusion of the review is stark. Despite the efforts of many committed politicians, government officials, service providers and community advocates, we do not have a system of effective or accessible mental health care. At all levels of government, within some of the professions and out in the wider community, there is a perception of general apathy, lack of accountability and lack of commitment to real change. While public understanding of mental health has begun to improve, the wider community remains relatively ignorant of the service crisis. Only when a family member needs care are they made aware of the gross deficits in care.
People with mental disorders, and their families, feel frustrated and let down by the system. Their goodwill, patience and support for the protracted nature of genuine health care reform have been dissipated. People whose lives have been affected are willing to back another five years of government national planning only if it is supported by genuine national leadership and commitment.
While mental health reform is difficult, and needs to be seen as occurring over years rather than weeks or months, those in need of services today require an urgent and substantial improvement in our mental health care system. To simply continue with the current inadequate pace of reform, perpetuate the same inadequate resource base, utilise the same governance structures and fail to invest in innovation and disease prevention, is to condemn many of the most disadvantaged and ill members of our community to many more years of abuse, neglect and very poor mental and physical health. It also puts at great risk the wellbeing of many other Australian families who are likely to require such services for the first time in future years.
• Community-based voices now favour a more proactive, more critical and more political approach. National and state governments have substantially underestimated this groundswell of disenchantment.
• Enquiries within several States over recent years have only scratched the surface of experiences of poor-quality care. Further agreements between governments are now in danger of being perceived as hollow and without integrity.
• The current oversight of mental health care reform needs to be extended beyond the National Mental Health Working Group of the Australian Health Ministers’ Advisory Council (AHMAC) to include heads of government.
Key issues related to deinstitutionalisation include….
Restricted access to existing services:
• The experience of current consumers of mental health care is that they have severely limited access to primary care (exacerbated by current declines in bulk-billing rates), emergency care, specialist care and rehabilitation services (Page 3).
• Current care systems are perceived to be chaotic, under-resourced and overly focused on providing brief periods of medicalised care, largely within acute care settings.
• Private psychiatric services are grossly maldistributed and involve large out-of-pocket costs, while access to specialist psychology and other allied health services has been restricted largely by lack of government or private insurance support.
• The demands on the carers and families of people with mental illness are increasing.
Ongoing human rights abuses and neglect:
• While the locus of care under the National Mental Health Strategy has moved from institutional to community-based care, no effective management system has evolved to provide either high quality care or the necessary supports for living productively within the wider community (Page 4).
• Persons with mental illness report ongoing abuse within hospital forms of care and ongoing abuse and neglect in the wider community. Overt abuse is reported to occur within emergency departments and other acute care settings of general hospitals.
• Persons with mental illness report ongoing discrimination in key areas of employment and insurance, and restricted access to basic welfare services and support.
“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.” (13, p.xv) Honourable Dr Brain Pezzutti, Chair, NSW Select Committee on Mental Health (Page 4).
The impact of changes in psychiatric hospitalisation
The following information provides an overview nationally of the changes in psychiatric hospitalisation.
Central to the vision of the National Mental Health Strategy is the idea that an effective mental health service requires a core set of components, which place the locus of care in the community. The National Mental Health Strategy has therefore advocated a fundamental shift in the service balance, away from the historical reliance on separate psychiatric hospitals to the development of local, comprehensive mental health services. These should be linked to form a single, integrated service system that emphasises continuity of care, both over time and across service boundaries, mainstreamed with the health system as a whole. Stand-alone psychiatric institutions were central to Australia’s mental health system at the commencement of the Strategy, accounting for 49% of total mental health resources. By 1998 this reduced to 29% and total beds in institutions reduced by 42%. At the commencement of the Strategy, 55% of acute psychiatric beds were located in specialist mental health units in general hospitals. By June 1998, this had increased to 73% as a result of a reduction in stand-alone acute services and a 34% growth in general hospital-based beds through the commissioning of new or expanded units.
Protection of the resource base for mental health reform was imposed by the Federal Government. Federal mental health funding was quarantined from general health funding provided to States and Territories who subsequently agreed to maintain their previous level of mental health expenditure throughout the reform period. In addition, any savings arising from the downsizing of institutions was required to be directed back to new mental health service development.
New models of care, and the shift away from institutional care towards community care, have challenged the attitudes and skills of those working in mental health. Stigmatising attitudes to people with mental illness are still held by many clinicians and mental health professionals. It is important that practitioners acquire and maintain knowledge, skills and attitudes to provide quality services in this new service environment and ensure those with a mental illness play an active role in decisions regarding their treatment. More people with mental illness are living in the community which means stigma from community members has a more direct impact on consumers. Consumer participation in community life, as well as in mental health service and policy development, is important for recovery and improved quality of life and citizenship. Ongoing efforts to reduce stigma and discrimination continue to be important (Page 9).
Reference: Groom, G., I. Hickie, & T. Davenport. (2003). ‘OUT OF HOSPITAL, OUT OF MIND!’ A Report Detailing Mental Health Services in Australia in 2002 and Community Priorities for National Mental Health Policy for 2003-2008. Mental Health Council of Australia, Deakin West, ACT. Pages 2 – 9.