1. Home
2. Policy Portfolios
3. Psychiatric disability

Senate Select Committee on Mental Health: Inquiry into Provision of Mental Health Services in Australia

Introduction

The Disability Council of NSW was established in 1984 to advise the NSW Government on issues affecting people with a disability and their families. The Council's role includes:

• monitoring the implementation of Government policy in relation to people with a disability;
• advising Government on the effect and relevance of services for people with a disability;
• promoting the integration of people with a disability into the community;
• encouraging diversity, flexibility and innovation in the provision of services; and
• consulting directly with people with a disability.

The Disability Council also functions as the disability advisory body to the Commonwealth, commenting on Commonwealth policies affecting people with a disability and their families in NSW.

In recent years, the Disability Council has made representations to the NSW Legislative Council's Select Committee on Mental Health and subsequent discussion papers prepared by NSW Health. It is not our intention to repeat well-known statistics on mental health expenditures or the burden of disease and disability attributable to mental illness: the Disability Council's submission is underpinned by a human rights perspective and focuses on disability issues. The Disability Council has interpreted the Committee's terms of reference according to these broad dimensions. The comments of Councillors and mental health service consumers are summarised below.

Relevant issues from the Inquiry's terms of reference

The extent to which the National Mental Health Strategy has achieved its aims and objectives:

While the Disability Council fully supports the intent of the National Mental Health Strategy, it is of great concern to us that, despite reviews of the Strategy and increasing Commonwealth health funding over the past decade, actual expenditure on mental health services has not increased significantly over this period, relative to an increasing burden of disability associated with mental illness. The National Mental Health Strategy did not provide for adequate financial or human resources dedicated to the reform of mental health services in Australia. Although the Disability Council has always supported the process of deinstitutionalisation of mental health services in NSW, which can be attributed to the National Mental Health Strategy, funding urgently needs to be directed to community-based services, particularly long-stay service support, such as supported accommodation, and provision of community-based rehabilitation for people with chronic mental illness and associated disability, and people in recovery from acute episodes of illness. Until this happens, people with mental illness and psychiatric disabilities will continue to make up the greater part of our State's homeless, or be "reinstitutionalised" under the criminal justice system.

Many consumers are pleased with the integration of mental health services into mainstream public health settings; this is felt to reduce some of the stigma associated with mental illness, and to allow people to remain in their own communities. Some consumers have frequently expressed concerns about the difficulty of "getting into hospital" - although further exploration of this issue made it clear that they were describing the need for accommodation or respite services, rather than hospital beds. Adequate accommodation and domestic support is a critical component of mental health maintenance.

Please note that in acknowledging that there are insufficient beds numbers in NSW and that the availability of psychiatric medical and nursing support is less than optimal, the Disability Council is not in any way advocating a return to congregate care, or any service type that separates people with mental illness from their own communities.

The adequacy of various modes of care for people with a mental illness, in particular prevention, early intervention, acute care, community care, after hours crisis services and acute care:

The persistent model of care for people with mental illness and psychiatric disability in NSW has been inpatient treatment of acute episodes of illness, particularly psychotic illness. This model developed in response to the initial policy focus of the National Mental Health Strategy, while people with chronic, long term or episodic, mental illness and significant disability associated with this have been, until recently, largely overlooked. This is complicated by a shortage of dedicated mental health beds and increasing demand, resulting in an inappropriate use of public hospital accident and emergency beds. Prevention and early intervention services are largely under-resourced, such that consumer contact with the mental health system often only occurs when a person's symptoms are such that he or she is in psychiatric crisis.

Further, where part of a person's treatment involves accessing services in stand-alone public psychiatric hospitals, these facilities are described by consumers as run-down and under-staffed. Devolution of public psychiatric hospitals should not imply a parallel degradation of the quality of service provided in these facilities.

It is not clear how effectively the savings achieved from the devolution of specialist psychiatric hospitals have been applied to the development of community services. Community services are frequently described by consumers as over-stretched and sometimes inaccessible.

Prevention & early intervention services, where they exist, should include a model of intensive family support, to acknowledge the person with a mental illness as a person within the context of family. This could provide education, about available resources, how to recognise the onset of illness and strategies to support the person when they are becoming unwell and during their recovery, in order to maintain the integrity of the family unit.

Related to this, there is an urgent need for respite services for families who are supporting a family member who has a chronic mental illness.

Opportunities for improving co-ordination and delivery of funding and services at all levels of government to ensure appropriate and comprehensive care is provided throughout the episode of care.

Chronic mental illness and its associated disability is difficult to define as episodic. Similarly, people who have a dual diagnosis typically require ongoing support, rather than something that can be tied to an episode of care. This use of language may be seen to reinforce the dominant "acute episode" model of care.

The extent to which unmet need in supported accommodation, employment family support and social support services is a barrier to better mental health outcomes.

Beyond biomedical interventions, including therapeutic support, recovery is facilitated by appropriate accommodation, employment, socialisation and health education, with different levels of support, according to individual needs. These are service types that rely on a high level of interdepartmental and inter-sectoral co-operation and co-ordination - beyond the development a joint guarantee of service or a memorandum of understanding. Anecdotal evidence suggests that consumers remain heavily dependent on case-manager support and advocacy to negotiate access to generic services. The National Mental Health Strategy failed to make appropriate provision for the increasing demand for mental health services. Consequently, large numbers of people with psychiatric disability are living on the streets, or are in gaol.

Special needs groups.

The delivery of mental health services to Indigenous Australians needs to be developed in culturally appropriate ways. The Disability Council notes with interest last year's COAG proposal that the delivery of services - including health services - will be based on a whole of Government approach, with direct negotiations with Indigenous communities at a local level.

The Disability Council maintains that it is inappropriate for young people with mental illness - especially those who have been newly diagnosed - to be treated in adult services. Consumers report that this is particularly distressing when the young person is in the same ward (or A&E unit) as an adult with mental illness, who is experiencing acute illness - or disability associated with chronicity - and sees this as his or her "future". It is critical that services are established that address the developmental needs of children and young people. Related to this is the need for support services for young people who provide care for a parent who has a mental illness.

Access to mental health services for people with other disabilities remains very problematic. From a consumer perspective, linkages between government disability services and mental health services are very poor. People who have an intellectual disability or a substance abuse problem find it almost impossible to access mental health services in a timely and appropriate fashion.

There is also limited system capacity to provide mental health services for people with physical disabilities or mobility problems, because many mental health services remain physically inaccessible.

Another major issue from Disability Council's perspective is the lack of mental health services for people who are deaf - including a shortage of suitably trained Auslan interpreters.

There is little provision made for support of people with mental illness who are from culturally or linguistically diverse communities. Notable exceptions are the model developed by the NSW Transcultural Mental Health Centre and, nationally, the resources accessible via Multicultural Mental Health Australia.

The over-representation of people with a mental illness in the criminal justice system and in custody.

The National Mental Health Strategy is broadly consistent with the UN Principles and the National Standards for Mental Health Services emphasise human rights, dignity and safety. Nonetheless, in NSW at least, people with mental illness and psychiatric disability can be detained indefinitely, at the discretion of the Minister for Health, or the Governor of NSW, under the discretionary powers that still exist in NSW legislation. No such restriction is applied to any other person in contact with the criminal justice system: the Disability Council believes that this is an abuse of human rights.

Apart from the need to ensure that systems are in place to identify and divert people who are at risk of contact with the criminal justice system, there is an equally important need to provide timely and effective mental health and associated support services to people who are already in custody. It is essential that such services are available in all prisons and detention centres, to prevent human rights abuses in custody.

The practice of detention and seclusion within mental health facilities and the extent to which it is compatible with human rights instruments, etc.

The Disability Council recognises that in some cases detention and seclusion within a mental health facility may be the most appropriate (including "least restrictive") form of treatment, provided that such detention and seclusion can be demonstrated to be consistent with human rights instruments. However, the Disability Council has noted the shortages of community beds and support staff (psychiatrists, psychologists and psychiatric nurses) for people with mental illness and psychiatric disability, while the method of admission to mental health facilities in NSW is via accident and emergency units. It is perhaps inevitable, under these circumstances, that staff with limited experience or professional training in psychiatry should respond to some of the behaviours associated with mental illness with calls to security services or police. Consequently, people with mental illness are frequently detained in accident and emergency units of public hospitals under chemical and/or physical restraint, with little understanding of what is happening to them. This practice is clearly neither "most appropriate" nor "least restrictive".

Conclusion

Consumers are finding it increasingly difficult to access care and support - whether this is in an acute medical setting, or ongoing medical, social and emotional support. There is an inconsistency between the National Mental Health Strategy's vision of community-centred services and the allocation of resources at a State level. Consistent with the National Mental Health Strategy, the NSW Health Annual Report of a decade ago identified the expansion of community-based services and the development of service provision via the non-government sector as priorities in mental health services in NSW; it also emphasised Indigenous Australians, people from culturally and linguistically diverse communities, and people within the criminal justice system as priority populations. It is the view of the Disability Council of NSW that, after more than ten years, these priorities remain the same.

Andrew Buchanan,
Chairman, Disability Council of NSW