Mental Health Policy Changes in Australia

Mental Health Policy & Practice Mental Health Policy Changes in Australia Karyn Krawford, November 2019 Introduction People who were considered ‘mentally ill’ in Australia historically were publically shamed, locked up as criminals with no rights in institutions such as ‘Asylum for the Insane’ established in Tasmania in 1834. An overfunding of general hospitals and underfunding of mental hospitals transpired (Meadows et al, 2012) until 1993 when the first National Mental Health Plan was rolled out by federal government to provide mental health services separately from general health services and implement rights and standards for consumers. Since 2017 the National Mental Health Strategy evolved from a fifth plan building on all the previous plans and includes a suicide prevention plan that several states have since adopted (COAG, 2017), amid a spend of over $8 billion on mental health services in 2013-14 (Hungerford et al, 2018). The effectiveness and impact of policy changes and government reform on both consumers and carers are heavily impacted by highly funded key priorities specified in the fifth plan. These include constructing a holistic government service delivery, increasing community services and organisations, adopting a caring, consumer approach, suicide prevention, and improving services for the unique needs of Indigenous populations, among many other wide reaching changes. Changes in the last ten years have been significant in redirecting focus to community based services and rolling out to state and local governments. It is important to consider how changes have been implemented on ground level through local governments, hospitals, community councils and networks in order to determine how impacted consumers and carers have benefited and if service standards have conformed to quality standards framework (Hungerford et al, 2018). While changes have been progressive with spending increased dramatically nationally, key service providers have reported frustratingly many gaps exist between the fifth plan intentions and progressive outcomes. Unclear measurable, transparent and detailed planning exists within the implementation of the plan. Cultivated from the National Mental Health Policy developed in 2008, the fifth National Mental Health Plan was developed by the National Mental Health Commission and implementation, performance and monitoring responsibilities of the plan lie with the Australian Health Protection Principle Committee which consists of multiple health committees (COAG, 2017). The Mental Health Commission includes a diverse number of people; those with lived experience of mental health illness, a variety of service providers, indigenous organisations and state governments in order to capture a broad view of the problems and industry (COAG, 2017). This change in forming holistic government groups is partially to ensure all stakeholders take ownership, engage with objectives and become accountable to the national service and delivery standards requiring the multi layers of government to conform (Hungerford et al, 2018), yet strong criticism has arose from major mental health service providers such as, there is no implementation plan according to Orygen (2019), a NFP organisation providing policy advice, on mental health for young people, or monitoring framework and evaluation available of the previous plan. The critical area of funding is not transparent between state and federal government (Orygen, 2019) and there is a need for an accountable, transparent and a stronger system which is important to ensure each layer of government is held accountable (Hungerford et al, 2018; Mission Australia, 2019) “there is a lack of clarity in the roles, responsibilities and accountabilities between and across governments” (Orygen, 2019). Furthermore, Sane Australia (2019), state the plan has not been resourced well and a problem exists with rationalising the spending in some areas with any measurable outcomes or utilising existing evidence and recommendations. These issues are critical to consumers and carers experiencing better overall outcomes (Anglicare Australia, 2016) and importantly reaches and supports those in need (Beyond Blue, 2019). Responding to these appraisals of the plan, the National Mental Health Commission released a report recently advising it recognises the challenges in monitoring the implementation of the plan and has steps in place to do so, while adding government limitations exist in influencing non-government organisations (NGOs) stakeholders implementing the plan (Mental Health Comission, 2019). Another influential report from the World Health Organisation addressed standards of mental health services in Australia was most influential in closing institutions and mainstreaming support and services so people can live in communities supported (Hungerford et al, 2018). Historically hospital Psychiatric bed services in Australia have withdrawn overall with a focus on moving from Psychiatric hospital beds to a community services, holistic approach as part of the national reform (Meadows et al, 2012) and following a report called The Richmond Report, which was a Royal Commission to investigate adverse Psychiatrists in private hospitals of NSW following increasing readmission rates and was the cause of de-institutionalisation for all states. Even though an increase occurred in community based services, in 2011 NSW continued to focus on stand-alone Psychiatric hospitals in violation of the National Mental Health Strategy in disregard of evidence and consequently the system went backwards with the closure of many community groups who didn’t receive the allocated resources which resulted in increased drug and involuntary hospital admissions. Eventually new legislation included a holistic approach and new policy is represented by all stakeholder services with an evidence based recovery approach and addition of an independent watchdog (Meadows et al, 2012). The recovery approach is the choice of government as a process to integrate a truly consumer centred approach with underlying principles of their journey to health inspired by hope, optimism, meaning, equality, self-confidence, social inclusion and community engagement. It respects and gives rights to people, allowing them to partner with health professionals of their choice (Hungerford et al, 2018). Obstacles occurred with integrating this model into an existing system that is dominated by a bio medical approach because the clinically based medical model focuses on cure (Hungerford et al, 2018) and needs to include other systems central to an individual’s wellbeing like housing, education and employment (Orygen, 2019). For example, even though government emphasises the importance of a holistic, consumer orientated plan, a recent government report summarising mental health services today (Australian Institute of Health & Welfare, 2019), consists of approximately ninety percent of information about hospitals, Psychiatric services, spending on Psychiatric services and clinical issues. There is very little observed evidence of the above mentioned changes. In contrast to NSW, Queensland historically had small retracted health centres in districts managed under a chief Psychiatrist experiencing progressive development in both private and public sectors even with lower than average funding. Psychiatric hospitals were commissioned to close in 2015 (Meadows et al, 2012), even though several hundred are still in operation. Positive Recognition of this reform portrayed the state as leading in mental health reform and it now has a five year plan in place till 2023. This is a big improvement from previous government’s one year plan (Meadows et al, 2012), and allows for specialist services to address different consumer groups needs such as alcohol and other drugs services which is a top government priority (Queensland Mental Health Commission, 2018) and specialised children’s services (Meadows et al, 2012). In fact Queensland is the only state with a mental health court concerned with equal and fair rights, causes of serious deaths and incidents and other person centred needs. A person centred approach is the most common and growing theme in western countries allowing a person to participate in choosing their treatment (Hungerford et al, 2018), in line with government’s national stepped care approach that matches the care level and service required for each person’s need of which a stepped model can be viewed in the fifth plan from five population groups; a well and a ‘at risk’ population to a ‘severe mental illness’ (COAG, 2017). Orygen (2019), note however, that government needs to move beyond the stepped-care approach and articulate the language they use such as ‘severe mental illness’ with an evidence based model so that consumers don’t fall through the cracks if they don’t fit into one of these population groups. In addition, Meehan et al (2017) states most people in Queensland hospitals could be discharged if more ‘step-down’ options and community services were available. Which would be possible by growing the NGO sector (Meadows et al, 2012). Despite these challenges in reform, Australia is on par with other developed countries agenda to close long-stay hospitals and focus on community alternatives (Meehan, Stedman, Parker, Curtis & Jones, 2017). The shift from hospital beds to consumer and community orientated services are important areas of the plan nationally because most of the most common mental health issues today which are not severe, would not generally be treated in hospitals. These include; anxiety disorder (14.4%) which includes Post Traumatic Stress Disorder of which much is war related, mood disorders (6.2%) which include depression, bipolar (6.2%) and substance use that includes alcohol related issues (5%) (Hungerford et al, 2018). The newly whole of government approach includes state frameworks recognising the need for actioning a suicide prevention strategy (Meadows et al, 2012) which is a critical focus of the plan as eight deaths per day occurred from suicide in 2017 with men 40-44 and over 85 years as the highest groups, while Indigenous people are twice as high than non-Indigenous and people living in remote areas have a 30% increased rate (Hungerford et al, 2018; COAG, 2017). Unfortunately these figures are likely to be much higher than what is recorded and available (Productivity Commission, 2019), nor has there been any reduction over the last decade (COAG, 2017). To address these problems it is important to identify early risk factors, develop protective factors as well as quality of life for individuals and families in general and address the needs of Indigenous populations especially younger people aged 15-19 who are nearly six time more likely to die by suicide (Hungerford et al, 2018). Indigenous worldviews are different and therefore culturally sensitive community prevention programs are necessary (Mission Australia, 2019). Following much criticism about the current fragmented approach, the fifth plan includes a Suicide Prevention Committee and a special Aboriginal and Torres Strait Islander Subcommittee. These groups will work on the implementation of this plan which states community engagement is essential to improving outcomes. Additionally, governments will support community approaches at a regional level (COAG, 2017). People at risk will benefit by understanding which services they can access and carer and families will gain extra support (Hungerford et al, 2018). NFP organisations Beyond Blue and Lifeline equally received the largest portion of the $72.6 million budget allocated by Federal Government for suicide prevention (Parliament of Australia, 2019) who have ambitious plans in place such as Beyond Blue’s universal suicide prevention system which implements compassionate and trained staff in every health workforce and safe café and discretionary setting places in strategic environments in some states. It believes it will help people get the support they need at times of distress (Beyond Blue, 2019). In conclusion Australia has and still progressively shifting mental health services away from traditional Psychiatric hospital based treatments to a more consumer friendly, person centred, holistic and caring approach in supportive community environments. Service providers in the non-government sector are progressively addressing critical government priorities such as suicide prevention and supporting Indigenous populations. Government appears to recognise gaps and further details are critically required to bring about outcomes in areas of priority within the fifth plan and while the plan details accountability through the whole of government for mental health services, it is unclear this is occurring at the current time. If further transparency is to be developed above, then similarly the partnering non-government organisations below should provide clarity on the productivity and standards they implement. With the vast amount of research, evidence and detailed reporting from wide ranging mental health professionals and organisations, the ball is plainly in the government’s court and it now needs to take action. Finally, it is greatly important to point out the shortfall in space to include many other significantly important areas of the fifth plan and its effects on consumers, carers and families which are early intervention and prevention changes and improvements in dealing with stigma. Reference list Anglicare Australia (2016) Fifth National Mental Health Plan Draft for Consultation. Australia. Retrieved from: https://www.anglicare.asn.au/docs/default-source/default-document-library/anglicare-australia-response-to-the-fifth-national-mental-health-plan-draft-for-consultation.pdf?sfvrsn=4 Australian Institute of Health and Welfare (2019). Mental health services in brief 2019. Canberra: AIHW. Retrieved from: https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/summary-of-mental-health-services-in-australia Beyond Blue (2019). Submission to the Productivity Commission Inquiry into the economic impacts of mental ill-health. Australia. Retrieved from: https://www.beyondblue.org.au/docs/default-source/policy-submissions/beyond-blue-submission-to-pc-mental-health-inquiry---april-2019.pdf?sfvrsn=e580bcea_8 COAG Health Council (2017). The fifth national mental health and suicide prevention plan. Canberra. Retrieved from: Analysis and Policy Observatory Website: https://apo.org.au/node/114356 Hungerford, C., Hodgson, D., Bostwick, R., Clancy, R., Murphy, G., de Jong, G., & Ngune, I. (2018). Mental health care (3rd ed.). Milton, QLD: John Wiley & Sons. Meadows, G., Farrell, J., Fossey, E., Grigg, M., McDermott, F., & Singh, B. (2012). Mental health services: The Australian states and territories. In Mental health in Australia: A collaborative community practice (3rd ed., pp. 118-154). Melbourne, Australia: Oxford University Press. National Mental Health Commission (2019). Monitoring mental health and suicide prevention reform: National Report 2019. Sydney: NMHC. Retrieved from: https://www.mentalhealthcommission.gov.au/monitoring-and-reporting/national-reports/2019-national-report Mission Australia (2019) Submission on the Fifth National Mental Health Plan. Australia. Retrieved from: https://www.missionaustralia.com.au/publications/submissions-and-reports/disability-and-mental-health National Mental Health Commission (2019) Monitoring mental health and suicide prevention reform: National Report 2019. Sydney. Retrieved from: https://www.mentalhealthcommission.gov.au/getmedia/f7af1cdb-d767-4e22-8e46-de09b654072f/2019-national-report.pdf Orygen. (2019) Response to the draft Fifth National Mental Health Plan. Australia. Retrieved from: https://www.orygen.org.au/Policy/Policy-Areas/Government-policy-service-delivery-and-workforce/Government-policy/Response-to-the-draft-Fifth-National-Mental-Health Parliament of Australia, Department of Parliament Services. (2018). Budget Review 2018-2019. Research Branch. Canberra. Retrieved from: https://parlinfo.aph.gov.au/parlInfo/download/library/prspub/5982057/upload_binary/5982057.pdf Productivity Commission of Australia. (2019). SANE Australia: Mental Health Inquiry 2019. Australia. Retrieved from: https://www.pc.gov.au/submissions-search?collection=productivity-commission-sub-web&f.Inquiry%7CT=mental+health&query=michelle+blanchard Queensland Mental Health Commission (2018). Shifting minds: Queensland Mental Health, Alcohol and Other Drugs Strategic Plan 2018-23. Australia. Retrieved from: https://www.qmhc.qld.gov.au/sites/default/files/files/qmhc_2018_strategic_plan.pdf 11 Karyn Krawford, Mental Health Policy, 2019