So we beat on,boats against the current,borne back ceaselessly into the past – Continued inaction on public mental health services

So we beat on, boats against the current, borne back ceaselessly into the past.

F. Scott Fitzgerald: The Great Gatsby

Psychiatric care in Australia remains underfunded when compared to physical health. In 2014–2015, mental health received around 5.25% of the overall health budget while representing 12% of the total burden of disease (Australian Medical Association (AMA), 2018). This is despite numerous enquiries, commissions and reviews (Rosenberg et al., 2015). One consequence is that acute bed occupancy rates are so high, and average length of stay so short, that Australia has the third highest readmission rate among the Organisation for Economic Co-operation and Development (OECD) countries for patients diagnosed with schizophrenia, and the fourth highest unplanned readmission rate for mental health (Allison and Bastiampillai, 2015). Such underfunding and its consequences are emblematic of the neglect of public mental health services in Australia. Inaction persists in spite of two recent examples demonstrating the consequences of neglect in the past year: the mental health bed and staff shortages at Royal Hobart Hospital in 2017 and the life-threatening dereliction of care uncovered by the Oakden Aged Mental Health inquiry in 2018.

Neglect

The neglect of public mental healthcare arises, in part, from the stigma and consequent marginalisation faced by people with mental illness, their families and clinicians caring for them. This is sometimes seen in the physical planning and design of healthcare facilities, where acute mental health inpatient facilities are often located far from the main hospital campus or segregated zones in emergency departments. In this way, the physical displacement of mental health facilities mirrors the marginalisation, or alienation of mental illness, as did the asylums of the past.

Patients and carers are sometimes consulted in planning specialist mental health services; psychiatrists are frequently not, indicating a reluctance to seek expert medical specialist advice. For example, the National Mental Health Commission’s review of mental health services gives equal weight to submissions from unnamed individuals as those of organisations like the Royal Australian and New Zealand College of Psychiatrists. Similarly, there is a lack of psychiatrist representation on peak policy bodies such as the Mental Health Advisory Council to the A.C.T. Government.

Funding for mental health services fails to keep pace with more legitimatised areas of healthcare such as surgery or intensive care. The common relegation of Mental Health to a junior ministerial portfolio in most states/territories of Australia further marginalises the specialty.

This inaction occurs despite a range of reports and reviews from bodies such as the National Health and Hospitals Reform Commission, the National Advisory Council on Mental Health, the National Mental Health Commission and the Australian Medical Association that have all pointed to the need for reform of mental health service delivery and increased funding (AMA, 2018).

Inaction and its consequences

Rather than increased funding, the opposite has occurred with staffing, infrastructure and resources constrained by state and federal governmental drives for ‘efficiency dividends’. Accordingly, these public sector services remain seriously underfunded, with insufficient capacity for timely and effective treatment of patients. Furthermore, acute mental health services have been sidelined in favour of ultra-specialised programmes with wide variations in levels of effectiveness (AMA, 2018). This under-resourcing means that public mental health services cannot recruit, retain and develop a healthcare workforce or have adequate infrastructure to provide comprehensive care for the most severely mentally ill (Royal Australian and New Zealand College of Psychiatrists [RANZCP], 2017). This workforce is winnowed by increased risks of violence and abuse arising from the staffing and resource shortfalls in the sector (RANZCP, 2017). This further exacerbates staff recruitment problems (RANZCP, 2017). The situation is compounded by the under-resourcing of overburdened emergency and general hospital facilities, with the result that psychiatrists are increasingly pressured to assume care in inappropriate situations.

Strained and under-resourced services cannot invest in clinical research that can inform evidence-based care, let alone host academic appointments that can improve recruitment and retention of the medical workforce (RANZCP, 2017).

There have been attempts to address deficiencies in the provision of community care by funding non-governmental organisations (NGOs), including through primary health networks, but without consideration of their capacity to undertake these greatly enhanced roles. As a result, care for some of the most severely ill has been contracted out to NGOs staffed by a workforce of variable training who are dependent on the renewal of short-term contestable contracts. Case management within mental health services is largely restricted to people on compulsory community treatment.

The National Disability Insurance Scheme (NDIS) has worsened an already dire situation as the sole gatekeeper to these services. Despite their complex needs, many people with severe mental illness are often not considered as having permanent disability and therefore excluded from services they previously accessed. Even if patients are accepted by the NDIS, clinicians are often excluded from designing the packages that they receive resulting in poorly targeted but expensive care.

What needs to be done

Psychiatry is the only speciality where care for the most complex patients is contracted out to the voluntary and non-governmental sector. Everyone with a mental illness should have ready access to quality mental healthcare in the public sector that is appropriate to their needs. Care for complex and persistent disorders across the age range is exactly the remit of adequately resourced and staffed public mental health services (RANZCP, 2017), in collaboration with other health professionals and services, private and public. This will require adequate funding of care, together with step-wise plans for implementing evidence-based care (McGorry and Hamilton, 2016) with health, social and system domain indicators as measures of accountability (Rosenberg et al., 2015).

To improve access to acute care, there needs to be increased provision and staffing of public inpatient acute mental health services, in parallel with adequately resourced community services (AMA, 2018). There should be greater provision of supportive step-down care on discharge from acute services, adequate resourcing of public community mental health outreach psychological therapy and social support services. There needs to be better designed and funded collaboration between public mental health services and primary care to support high prevalence disorders (e.g. anxiety or depression) as well as disabling mental illness (e.g. schizophrenia, bipolar disorder) across the lifespan. Collaborative provision of general medical care in relation to dental disease, cardiovascular disease, obesity and diabetes for often socially disadvantaged persons with serious mental illness in this respect is essential. The NDIS must give equal weight to psychosocial disability as physical disability at the same level of functioning, and involve clinicians in planning care packages. People with severe mental illness should not be cut off from the meagre levels of support they already receive.

Ultimately, the inaction on the plethora of unimplemented service reviews and mental health commissions over the last few decades is a failure of will to act, and an ongoing indictment of our civil society. In a Sisyphean toil, psychiatrists struggle to provide care for persons with mental illness as a result of the failure of effective action to adequately resource public mental health services. If, as a society, we are unable effect such significant change, the boat of mental healthcare will continue to beat on against the current of progress, marooning those with mental illness in the past.