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Putting the pieces together in mental health

Toby Hall - Croakey.org
February 2017

One of the disappointing aspects of the ongoing debate about resourcing Australia’s mental health system, has been the portrayal of hospitals and their role in caring for some of our most vulnerable citizens.

That they are dysfunctional. That they are cold and inflexible.

Public mental health services aren’t perfect. When people tell us of negative experiences while in acute care we must listen and learn.

But much of the commentary I’ve seen and heard does not describe the mental health services I’ve witnessed hospitals provide.

It also reveals a worrying misunderstanding of the way hospitals work in this space.

Early intervention and community-based support for people with mental health disorders is enormously important.

As the former head of one of Australia’s largest community service organisations, I’m intensely aware of how mental health issues affect a person’s ability to participate.

I agree there are inefficiencies in the system. It is overly focussed on acute care and not enough on prevention. We also need more resources to help people with mental illness before they reach crisis.

But why must it be a zero sum game?

We can’t overlook the crucial roles hospitals play, often when people are at their most vulnerable – a role we are already struggling to provide based on our resources.

Public hospitals provide far more than acute in-patient care. At St Vincent’s, we deliver integrated out-patient clinics and community mental health teams that provide care in people’s homes.

We’re the ones that chase up people who don’t engage, who are reluctant to receive care and who don’t voluntarily attend appointments and come in for follow-ups.

For example, among homeless people – particularly rough sleepers, who reportedly suffer post-traumatic stress disorder at rates four times higher than Australia’s mainstream population – while we look to collaborate with community providers wherever possible, we’re often the first port of call for support and intervention.

And as for the suggestion that acute care isn’t sufficiently person-centred – that people are required to fit into the system rather than the other way around – that’s a serious misrepresentation.

When a person struggling with a mental health issue comes into one of our services, we work with the whole person. We take into account their family situation, housing and employment goals, and their hobbies and interests.

St Vincent’s Hospital Melbourne was the first in the country to add an employment specialist to its clinical mental health services. It has housing workers based in its inpatient unit.

It also has staff specifically employed because of their lived experience of mental illness and recovery in order to better care for and support patients.

Public hospitals are frequently far closer to, and are more connected with, the range of services that are crucial to a person’s recovery than GPs, who often work in isolation.

Community organisations rely on hospitals to provide 24 hour assessment and safe management of risk so they can continue to provide effective care.

Public mental health services are also key in cutting the number of suicides, particularly given the National Mental Health Commission’s aim to reduce the suicide rate by 50% over the next decade.

The evidence tells us a person with mental illness is at their greatest risk of suicide immediately after being discharged from hospital.

If a person is discharged before they’re ready, it can have disastrous consequences.

We want to contribute to reducing this tragic figure, but we need more, not less, resources in public hospitals to do our job properly.  

I’ve long admired the way New Zealand reformed its mental health services.

In NZ, the community sector now receives around 30% of total mental health funding. But this rebalancing was the result of real funding increases, not at the expense of hospital-based public mental health care.

The introduction of purchaser-provider arrangements in NZ and the UK have also worked well and can work here as the Commission proposes.

Using Primary Health Care Networks to purchase services and bridge gaps between the different arms of the mental health system also shows great promise.

If done right, the proposed arrangements should improve continuity of care and ease the pressure on public mental health services over time.

But the networks are still developing relationships – particularly with acute care providers and the community sector – and we need to allow them the time to build their capacity before making them the foundation of Australia’s mental health system.

We also need to keep growing the expertise of the NGO and primary healthcare sectors as they take on larger responsibilities – hospitals have a role to play in this.

The new Minister for Health, Greg Hunt, has said he will make mental health a key priority of his time in the portfolio, I welcome that.

I hope in doing so he listens to the diverse range of voices in the mental health sector and not just those who shout the loudest or who are adept at achieving the greatest media coverage.