What States Can Do - Part VIII: Reforming mental health


Around the world, there is a burgeoning mental health crisis with governments at all levels struggling to cope, let alone improve services in a meaningful way. While a large number of governments moved in the 1980s to 'deinstitutionalise,' this only served to shift the problem to families, suburbs, city streets and shelters with insufficient support in the community.

In South Australia desperately needed root and branch reform of mental health had been delayed, put into the 'too hard basket'. While attention and massive financial resources had been invested in improving public hospitals to grapple with emergency department waiting times and surgery waiting lists successive governments had given insufficient attention to mental health. It was less politically 'visible', even though in Australia about 20% of the population is affected by mental ill health.

For decades mental health support had centred on hospital care - delivered when a person fell seriously ill. People suffering from mental ill health were also given inadequate levels of support in their homes either before or after hospitalisation. This was particularly emphasised to me by Lloyd Sederer, a psychiatrist and head of mental health in New York. During a visit to Adelaide he told me our system was too disproportionately focused on bed care for serious episodes of mental illness.

Many people with a mental illness would enter and then be discharged from psychiatric hospitals or wards back into their homes without any concerted attempt to break the cycle.

In 2005 I asked South Australia's Social Inclusion Commissioner, Monsignor David Cappo, to devise a reform strategy so that our state would be a leader in mental health not a follower. The result of his investigation was the "Stepping Up" report, released in February 2007. Cappo's report became our blueprint for a comprehensive 'ground up' revision of our mental health system. It is now influencing the national mental health agenda.

The key focus of Stepping Up was to add extra levels or 'steps' of care and support between acute hospital care and mental health support in the community. Rather than a 'one size fits all' approach 'consumers' of our mental health system are able to step up to more intensive health care if they are becoming unwell and step down to other graduated support services as they get better.

This approach makes sense for patients and for the system. It places less burden on the expensive, acute end of the health system including emergency departments in public hospitals. It also means that people with mental illness can receive a more appropriate level of care closer to where they actually live. Importantly it is our Community Mental Health Services agency - working closely with consumers and their families - which drives the transition or movement across the various levels of care.

Since the Stepping Up report was released more than $300 million has been invested into rebuilding, restructuring and renewing South Australia's mental health system so that it is better integrated and more balanced in delivering an improved quality of care. There is also now a bigger investment by the Federal Government in mental health. As a result of this cooperation more than 250 additional mental health beds and places will be available in South Australia within three years. 74 of those beds and places have already been delivered. In addition, 243 of 262 social houses, with attached mental health support for residents, have been built and tenanted.

A big capital works program is a key part of our mental health reform with a $142.6 million, 130 bed new acute mental health and substance abuse central hospital being built alongside beautiful but now totally unsuitable 19th century buildings. Buildings of the original Glenside psychiatric hospital were recently refurbished as the Adelaide Studios of the South Australian Film Corporation. This park-like location will become a shared campus with arts, housing and retail outlets next to the new purpose built mental health facilities. This approach is designed to help de-stigmatise mental illness. People with a mental illness are now being treated with greater dignity, part of our community. No longer locked behind barbed wire, the new buildings are better designed to keep patients safe without feeling like prisoners.

Extra beds are also being provided across metropolitan and country areas enabling patients and carers better access to services closer to their homes. In some cases hospital level services are even brought into a patient's home.

Very importantly, there has been a greater emphasis on new and much needed 'intermediate' steps to make the new system work. Each Intermediate Care Centre (ICC) is a fifteen-bed clinical service in a home-like setting. ICCs involve multi-disciplinary, nurse led teams with patients generally staying for up to two weeks. 92 places have been made available in metropolitan and country areas. We now also have Community Rehabilitation Centres which are housing clusters with on-site 24 hour support. In these centres consumers learn independent living skills with support provided to increase social and recreational opportunities. Patients stay between three and twelve months.

Our mental health system has now embraced a Housing and Accommodation Support Partnership which provides long term affordable housing with up to 24 hour support. This allows people with mental illness to live more successfully in the community with close assistance at hand when necessary to help prevent them returning to hospital.

In addition to the new stepped system of care, South Australia is also developing six Community Mental Health Centres. These new Centres replace the large number of fragmented services, integrating them into a single site. The Centres provide mental health information; advice; support; assessment; crisis response; outreach; assistance to people presenting to emergency departments; assistance to people in need of rehabilitation support; and counselling.

Each centre employs a team of mental health professionals working in partnership with consumers, their carers, their GP or nominated health care workers to provide co-ordinated care.

Our Assessment Crisis Intervention Service (ACIS) has been expanded to run 24 hours, 7 days a week which we hope will take pressure off hospital emergency departments.

I appointed our first ever Minister for Mental Health and Substance Abuse. This move was designed to give mental health a sharper focus and more 'grunt' within government.

The Stepping Up report and ensuing programs have attracted considerable positive attention. In an unprecedented move nationally Monsignor Cappo and fellow mental health reformers Pat McGorry and Frank Quinlan, were last year asked to address the Prime Minister and all Australian Premiers and Chief Ministers at the Council of Australian Governments.

I am pleased that the Federal Government has announced that mental health reform is a key second term priority with a record $2.2 billion committed for its Delivering Mental Health Reform Package. It will also significantly boost the availability of mental health services for up to 72,000 young people each year through its headspace program at 90 sites around Australia. In any one year 1 in 4 young Australians will experience some kind of mental health disorder. Suicide is now the biggest killer of young Australians aged between 15 and 24, causing 1 in 4 deaths.

The clear message to politicians is that early intervention gets better outcomes for patients and for taxpayers. It frees up resources for those with more serious and more protracted mental ill health. Waiting for a crisis costs lives, impedes recovery and further overloads an acute system that is not coping.

Early intervention with stepped care that is local is the way forward.

This Blog was published on the Center for National Policy website.

Mike Rann is Fellow for Democracy and Development with the Center for National Policy, Washington, D.C.