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Mental Health - 2011

29 Mar 2011

Many Australians experience a mental illness at some time in their lives. The medical profession has a key role in responding to the initial presentation of illness, making a clinical assessment and then taking responsibility for this and following it through with other health professionals and support services.  Accordingly, doctors, in particular general practitioners and psychiatrists, are well placed to identify the gaps in our current health system in the prevention, treatment and management of mental illness and to articulate the solutions that need to be put in place to improve the system for patients and support the medical profession in the medical and psychiatric care that they provide.

Several Federal Parliamentary Senate Inquiries have identified significant deficits in mental health funding. The National Health and Hospitals Reform Commission, the National Advisory Council on Mental Health, and the Mental Health Council of Australia, have all pointed to the need for reform of mental health service delivery arrangements.  To date, Government responses have been inadequate. In particular, there continues to be problems with community–based mental health services. These have not been appropriately structured or funded since the Burdekin reforms that moved much of the care and treatment of people with a mental illness out of institutions and into the community. For people with serious mental illness living in the community, there is also a particular difficulty in accessing care by psychiatrists in community–based settings.

In 2006, the Council of Australian Governments (COAG) mental health reforms made some significant changes to primary mental health care, improving access for people with mental illness to general practitioners (GPs), psychologists and other relevant allied health care workers.  More recent investments in further support and early intervention for young at–risk Australians, while not sufficient, were another small step towards improving primary mental health care in the community.  However, because the current State–run public health sector does not generally provide long–term mental health care in the community, many people with serious mental illness often have to be readmitted to hospital at short notice.  This puts additional pressure on the public hospital system because ongoing specialist clinical care in the community has not been available to them.  In short, there is a clear unmet and urgent need to fund more acute mental health care as well as ongoing care in settings other than hospitals for people with severe and enduring mental health problems.

All Australians with a mental illness deserve to have ready access to quality mental health care based on their particular needs. This requires a significant expansion of services, intervention and support for people with mental illness across the whole continuum of care.  Our Mental Health Policy identifies immediate priorities for government action and further investment across this continuum, including more investment and improved service delivery arrangements to support the following.

  • Prevention, destigmatisation and community understanding.
  • Early identification and intervention.
  • Community–based care.
  • Aged care.
  • Subacute care.
  • Acute care.
  • Crisis and Outreach care.
  • Special needs groups.
  • Social, environmental and economic determinants of mental health.

The Policy also identifies the key whole of system enablers that need to be in place to ensure that the continuum operates appropriately.  This includes having an appropriately sized and skilled workforce, better coordination across health care and support services, and significant additional overall investment in mental health services.

The 2010 COAG health reforms include agreement for the Commonwealth to have funding and policy responsibility for GP and primary health care services, including primary mental health care services.  It also includes agreement for the States to work with the Commonwealth on system–wide primary health care policy and integration of service planning and delivery. This will, as acknowledged in COAG’s communiqué, create strong incentives to support a healthier community and reduce pressure on hospitals and help reduce cost–shifting and blame–shifting.  These reforms provide the basis for a significant improvement in mental health primary care and community–based care funding and co–ordination of mental health care across the whole health system.

ENHANCING THE SERVICE CONTINUUM

1. Prevention, destigmatisation and community understanding

Background

Progress towards genuine national mental health reform will not occur unless community understanding of the experiences of persons whose lives are affected by mental illness improves.  Community awareness needs to encompass an understanding of the nature of mental illness and its treatment and recovery processes.

Priority areas for government action

  • Sustained national community awareness campaigns to increase mental health literacy and reduce stigma.
  • Public education campaigns for prevention and reduction in substance abuse.
  • Promotion of good health and resilience in young people at school and in the community.

2. Early identification and intervention

Background

Early identification and intervention, particularly for people aged 0 to 25 years of age, is required to not only prevent or delay the development of future mental health problems, but also to promote the necessary conditions for healthy mental development.

Priority areas for government action

  • Support for more online and telephone counselling and support services, such as Beyondblue and Lifeline, with comprehensive information about local referral pathways made available to ensure that patients get linked to the right service at the right time.
  • Increased funding for specific child and adolescent health services, including but not limited to Headspace. Funding is required for the development and implementation of a rigorously evaluated prevention and early intervention program across all children 0–18 years and into early adulthood. There also needs to be a focus on specific prevention and early intervention programs to target key disorders such as conduct disorders, anxiety disorders, depressive disorders, self harm or risk of suicide, children of parents with a mental illness. Parenting support services and parenting programs, particularly for at–risk groups, to assist with early prevention of mental health problems. Screening of infants, children and adolescents is required to identify early symptoms of mental disorders and illness as early as possible. Evidence–based school programs are also needed to help identify high–risk children and facilitate early referral to mental health professionals.
  • More youth friendly community–based services are required, including an increased in the number of Headspace centres to a minimum of 90.
  • Rollout of more Early Psychosis Prevention and Intervention Centre (EPPIC) services, to create a properly resourced, staffed and accessible national network of at least 20, is necessary so that early intervention in psychosis becomes the norm.
  • Support for more programs like Docs in Schools to enhance youth access to primary health care advice and support.

3. Community–based care

Background

Well coordinated and seamlessly provided community–based services, including both primary care and specialised community–based mental health services, reduce the need for hospital admissions and re–admissions and have the capacity to diminish the severity of illness over time.  In particular, many people with mental illness are appropriately diagnosed and cared for in respect of their physical and mental health problems by general practitioners in the community. It is imperative that community–based mental health care, including care provided in the community by general practice, is enhanced, supported, properly funded and better co–ordinated to ensure improved access to these essential services.

Priority areas for government action

  • More access to medical care and shared care is required in the community for people with mental illness through improved Medicare Benefit Schedule (MBS) arrangements including:
    • increased MBS rebates for longer GP consultations for patients with mental illness who often have complex and multiple physical and mental health issues that need to be responded to;
    • a higher rebate for a prolonged Medicare attendance item for patients in crisis situations;
    • increased MBS funding for psychiatric care and treatment provided to patients with complex conditions by psychiatrists in community–based settings;
    • improved MBS arrangements to acknowledge and reimburse for more shared care and complex consultations for patients with co–morbidities;
    • improved MBS arrangements to recognise and reimburse for non–direct patient care required for patients with mental illness including time spent finding suitable services for patients and talking to families; and
    • more funding and services for patients with dual diagnosis.
  • Improved access to private psychiatrists through sessional and visiting arrangements in community–based facilities is also required.
  • More access to mental health assessment facilities for public patients is required, including through more and better resourced mobile outreach teams operating extended hours for high risk patients.
  • Improved access to primary mental health teams is needed to provide support, one–off consultations, secondary consultations and some psychological services in GP premises.
  • Increased use of mental health nurses in general practice is also critical and can be achieved by reviewing and streamlining existing program arrangements to make access easier.
  • Improved access to specialised programs run out of community–based mental health services is needed to treat some specific clinical conditions that, for many patients, can be treated through community–based services including eating disorders, perinatal depression, personality disorders and self–harm.
  • Improved access is required to community–based mental health care services in rural communities, as well as urban communities, to the maximum extent possible, with the services customised to specifically meet local needs.

4. Aged care

Background

The Australian population is ageing with an increasing number of people living a healthy and independent life well beyond 65 years of age.  Physical illness, neurodegenerative diseases and disability are, however, associated with increasing longevity.  Anxiety and depression are common in the elderly and are often accompanied by physical ill health, dementia, disability or bereavement.  People with life–long mental illnesses and related disabilities will also experience age–related frailty and diseases.  Specific services for elderly people with mental health problems who are living in residential aged care or in the community need to be enhanced.

Priority areas for government action

  • Support is required for better linkage between aged care and mental health services through joint single entry points and contacts.
  • Support for better linkages between aged care psychiatric services in the public and private sectors and general practitioners to enhance shared care arrangements, including through the development of new consultative telemedicine case conferencing items on the Medicare Benefits Schedule.
  • More acute care beds specifically for the elderly with mental illness, separate from general adult mental health facilities, integrated with the general hospital and with geriatric medicine/rehabilitation services.
  • A mechanism to allow mental health services to arrange patient referral directly into residential and subacute aged care without going through an intermediary agency.
  • Ensure that the elderly with mental illness, who live in residential aged care and in the community, have access to specialised mental health assessment and care and dementia care services, including by mandating a formal aged care accreditation standard that requires aged care providers to make available residents’ access to medical care, including mental health care.
  • Expanded choices in mental health care for people in residential aged care through subsidized transport assistance for residents to attend consultations with general practitioners and psychiatrists and for patients to be properly subsidized for the cost of general practitioners and psychiatrists visiting aged care facilities to conduct consultations.

5. Subacute care

Background

To truly achieve psychosocial rehabilitation in the community, the service continuum must be enhanced to include subacute step–up and step–down type care as an alternative to inpatient admission, or to provide support after an acute episode of illness.

Priority areas for government action

  • More subacute beds (capital and recurrent funding) for long–stay patients and for residential rehabilitation.  This will need to be supported by AMA Bedwatch reporting and transparency arrangements to monitor the establishment of new beds and recurrent funding for sufficient episodes of care through Local Hospital Network service agreements. Priorities identified by local clinicians should be sufficiently resourced through these service agreements.
  • Step–up and step–down residential care, as an alternative to inpatient admission or for a period of transition after hospital discharge, with clinical services provided to residents by local clinical service providers through community–based services.
  • More respite care for people with mental illness and their families.

6. Acute care

Background

Acute care provides intensive treatment to a person who is experiencing an acute mental illness characterized by significant and distressing symptoms that require immediate treatment to de–escalate symptoms and reduce the risk of suicide and harm to self and others. While it is acknowledged that mental health care has been significantly de–institutionalised from hospital–based settings into community–based settings, there is still an ongoing need for this type of care and it needs additional resourcing.

Priority areas for government action

  • More access to acute care in public hospitals is required. This must include capital funding and AMA Bedwatch reporting and transparency to monitor progress in establishing the additional acute care beds.  It must also include funding for additional episodes of care through Local Hospital Network service agreements, with priorities that are identified by local clinicians sufficiently resourced through these agreements.
  • Increased access is required to specialised public outpatient services providing diagnosis and ongoing treatment and psychiatric care for people with mental illness and dual diagnoses.
  • Specialised mental health and dual diagnosis spaces, or departments must be established as part of public hospital emergency departments.
  • Additional capacity is required in public hospitals so that patients have the option of being treated in single–sex mental health wards.

7. Crisis and Outreach care

Background

A range of services is involved in crisis and outreach including health, police and ambulance services.  These services need to be coordinated and properly supported and expanded to facilitate the provision of appropriate care in these difficult situations.

Priority areas for government action

  • Increased investment in crisis intervention services is required, particularly for those with severe mental illness and/or those at risk of suicide.
  • Every acute mental health service should have a rapid–response outreach team.

8. Special needs groups

Background

There needs to be increased access to specialised mental health services for special needs groups, including people in indigenous communities, people with intellectual and other disabilities, those with significant drug and alcohol issues, older people, the homeless, people from culturally and linguistically diverse backgrounds, prisoners and people in detention centres.

Priority areas for government action

  • Targeted prevention and early intervention programs for high risk special needs groups and individuals are needed.
  • Increased support for drug and alcohol services, particularly to improve their expertise in assisting patients with mental illness, to expand options for GP referral for their patients requiring community–based support.
  • Specialised, culturally sensitive mental health services are required, targeted to meet the needs of special needs groups.
  • Cultural competence and sensitivity training and promotion are required for those who provide mental health care to patients from special needs groups.

9. Social, environmental and economic determinants of mental health, including education, employment, housing and supported accommodation, and social support

Background

There is a powerful relationship between a person’s social position, his/her living conditions and his/her health outcomes.  Poor access to education, employment, housing and social support all influence the amount of mental stress experienced and a person’s ability to access treatment and care.  Conversely, individuals experiencing mental illness are at higher risk of adverse social, environmental, economic, and health outcomes.  People with enduring mental health problems experience significantly higher rates of physical illness, and are likely to experience social exclusion and discrimination as a direct consequence of their difficulties.

Priority area for government action

  • Social, environmental and economic determinants of good health need to be addressed for people with mental illness, by improving access to  education, supported community–based housing and public housing, social support including services to prevent neglect and sexual abuse of children, vocational rehabilitation, employment support and post–placement employment support to increase the employment rate for people with a mental illness to at least that of people with other forms of disability through innovative models of employment support and more psychiatric–specialist employment service providers, and ensuring that these services link to community mental health services to enable appropriate clinical support, particularly for those with severe and/or chronic mental illness.

WHOLE OF SYSTEM ENABLERS

10. Workforce

Background

It is critical that the mental health service continuum is supported by a high performing and sustainable mental health workforce, able to deliver high quality, recovery–focussed mental health services in a safe and secure environment.  Increased investment in workforce training and support is needed to ensure that this goal is achieved and sustained in the future.

Priority areas for government action

  • Increased number of funded psychiatrist trainee places are required.
  • Appropriate psychiatrist trainee experience and scope of training must be provided, including through more training in private sector.
  • Increased number of other mental health workers, especially mental health nurses.
  • More continuing professional development and competency training opportunities for the primary health care workforce who choose to access it is very important, including for medical practitioners and practice nurses, at undergraduate and postgraduate levels and through online mental health courses and training and peer review groups as part of continuing professional development.
  • Health support services must be available for mental health workers and doctors.

11. Co–ordination and access

Background

The mental health service continuum should be coherent and coordinated, facilitating access for anyone who develops an acute or chronic mental illness.   It must be supported by genuine participation of consumers and carers in the design, delivery and monitoring of all facets of the care received in managing mental illness, with a focus on recovery.

Priority areas for government action

  • Consumer and carer participation needs to be improved with input into shaping programs and service delivery arrangements and support for those who care for people with mental illness.
  • Specific funding is required for mental health co–ordinators working with patients in the community and assisting with transition in and out of acute and subacute care.
  • Access to on–line support needs to be provided for medical practitioners, particularly primary care providers, and consultations should be facilitated via increased access to telemedicine and e–health technology.
  • Adequately resourced rural hospitals and general practices to enable timely and effective response to after hours medical and psychiatric care for patients with mental illness.
  • Medicare Locals and Local Hospital Networks must play a key role to improve co–ordination, reducing access gaps and designing and supporting appropriate referral pathways at the local level, particularly in relation to improving the following.
    • Linkages between public and private sector community–based health and medical services.
    • Communication and linkages and referral pathways between non–government community–based services and other mental health care and primary care services.
    • Linkages between hospital–based mental health services and multidisciplinary community–based and subacute services, to support stepped prevention and recovery.
    • Collaboration and linkages between primary mental health care and specialist medical mental health care services and expertise.
    • Discharge planning arrangement and community follow–up to ensure that there is clarity about where a person will be discharged to, in terms of community–based care, and ensuring that information is formally provided on discharge from acute or subacute care.
    • Integration between children, adolescent and adult mental health services to ensure smooth transitions for patients over time.
    • Linkages between education, child protection, family court, corrections, allied health practitioners and community–based mental health services.

12. Research

Background

Mental health services should be evidence–based and continuously improve as a result of sound research in the area of mental health service delivery, including community–based primary care mental health.

Priority area for government action

More mental health research should be funded, including in the areas of neuroscience (including an understanding of basic disease mechanisms), diagnosis, early intervention, clinical treatment and translational research in the area of mental health service delivery.

13. Increased funding

Background

Increased funding is needed to address the gaps in our current mental health services and enable the delivery of comprehensive, integrated and coordinated mental health services for all Australians who may develop an acute or chronic mental illness at any stage of their life.

Priority area for government action

An additional $5bn over four years is required now to expand health and social services, as outlined in this Policy. This is essential to ensure that there is a properly resourced, co–ordinated and supported system to respond to mental illness amongst Australians.


Published: 29 Mar 2011