PART 1

EXECUTIVE SUMMARY

INTRODUCTION

1.1 Mental disorders are a leading cause of disability in the community, accounting for 26 per cent of the non-fatal health burden in Victoria. In 2001, about 55 000 Victorians received services from the public mental health system and demand is expected to increase over the next 5 years. Public mental health services received a budget allocation of $588.5 million in 2002-03. This represents an average increase of 8.6 per cent per year since 1999-2000. In September 2002, the Department of Human Services released a 5 year plan outlining priorities for public mental health services in Victoria which recognises many of the things discovered in the course of this audit.

1.2 Poor mental health reduces an individual’s sense of wellbeing and may impact negatively on family and social relationships, and the wider community. Unemployment, substance abuse, physical illness, and social dislocation are generally higher among people with a mental disorder. People with psychotic disorders (such as schizophrenia) often experience considerable difficulty coping with everyday tasks, maintaining social relationships and occupational functioning.

1.3 In the 1980s and 1990s, Victoria led other States in legislative and service reforms in mental health. More than any other State, Victoria has transferred the treatment of patients and resources from stand-alone mental health facilities to community-based settings. Victoria’s Mental Health Act 1986 requires persons with a mental illness to be treated in the community wherever possible.

1.4 While alternative mental health services, such as those provided by general practitioners and private psychiatrists, may be accessed by consumers, public mental health services must be available for involuntary patients and are the major source of 24-hour crisis assessment and treatment.

1.5 Recent Statewide reviews report that it is becoming increasingly difficult for people experiencing a mental health crisis to gain timely access to appropriate mental health services. Consumers of mental health services and those who care for persons with a mental disorder report that the response to people in psychiatric crisis is often slow and inappropriate. This is problematic because a delayed service response can increase the risk of self-harm, suicide or violence, placing both the consumer and the public (potentially) at risk.

AUDIT OBJECTIVES AND SCOPE

1.6 The objectives of the audit were to determine:

• whether Area Mental Health Services (AMHSs) were providing timely and appropriate services to people aged 16 to 64 years who were experiencing a crisis associated with their mental illness, or who were at significant risk of experiencing a crisis;

• the impact of the current mental health service system on carers and families of people with a mental disorder;

• whether the rights of patients subject to community treatment orders and involuntary admission to hospital have been adequately protected;

• whether funds allocated to public mental health services have been distributed according to need; and

• whether an effective framework was in place to measure and monitor the effectiveness of mental health crisis prevention and response, at a Statewide and individual hospital level.

1.7 The scope of the audit was confined to adult public mental health services and the operations of the Department of Human Services, the Mental Health Review Board, and 6 of Victoria’s 21 AMHSs. Adult mental health services consume about 76 per cent of the State mental health budget. The audit focused on crisis prevention and response services because this is an area which has significant social and cost implications for the community. This audit preceded the release of the September 2002 Department of Human Services’ 5-year plan for public mental health services in Victoria.

AUDIT CONCLUSION

1.8 To assess the timeliness of service response, we examined 191 case files of people with a severe mental disorder who had presented to an AMHS and were rated as “urgent” by an AMHS clinician. People referred to private practitioners for assessment or treatment following initial contact with the AMHS were not included in the sample of files audited. Assuming our sample of 191 case files had been correctly assessed as urgent by AMHS clinicians, 65 per cent of initial service contacts rated as urgent did not receive a face-to-face assessment by an AMHS clinical staff member within 24 hours. Twenty-five per cent of urgent cases did not receive an initial face-to-face assessment by an AMHS clinical staff member for 7 or more days.

1.9 One important issue relates to the debate regarding the appropriate standard against which timeliness and appropriateness of service response during a psychiatric crisis should be measured. The relevant standards and guidelines are not universally accepted and there are differences in interpretation between the Department, AMHSs and mental health practitioners. AMHSs are also at varying stages in adopting the national standards. Accreditation against the national standards will commence in June 2003.

1.10 Professional advice received from the Victorian Branch of the Royal Australian and New Zealand College of Psychiatry is that clinical assessments of urgent referrals need to occur within one hour (allowing for travelling time) and, aside from exceptional circumstances, these assessments should be conducted face-to-face. Professor Harvey Whiteford, Chair of the 1997 National Mental Health Working Group for mental health standards, advised that:

“For presentations rated as urgent by an AMHS clinical staff member at the initial point of contact with the service, a clinically appropriate intervention should occur within 24 hours. This clinical intervention should, in most instances, be a face-to-face assessment by a clinical staff member or another appropriate clinician (e.g. general practitioner) determined by the AMHS. The intervention could commence as a telephone intervention where this is deemed by the AMHS to be clinically appropriate and sufficient to respond to the immediate needs of the consumer”.

1.11 Documentation in client files was used to establish the timeliness and appropriateness of service provision. The standard of this documentation was poor; a major finding of the audit. While the file audits were conducted according to a rigorous methodology using experienced mental health consultants who were familiar with the nature of both the files and the processes being audited, the poor documentation means that there may have been processes which occurred but for which there is no evidence on the file. The audit focused on what was documented. This should be taken into account by the reader. The audit accepted the clinical judgement of AMHS practitioners, specifically in relation to their assessment of risk and urgency of patient needs. The audit noted the need for clear guidance for practitioners to ensure consistency of service delivery.

1.12 The audit found that people in psychiatric crisis faced difficulty accessing acute psychiatric beds due to increasing demand pressures and static bed numbers in some regions. Aspects of service provision have been impacted by demand pressure, work force shortages, significant gaps in completion of key service delivery processes (including comprehensive assessments, individual service plans and case closure plans), and limited involvement of consumers and carers.

1.13 Carers and families believe services for consumers, and support for carers and families, are inadequate. Carers indicate that they require better information, education, consultation, training and support.

1.14 The operational efficiency of the Mental Health Review Board has improved significantly ($472 per completed case in 1987-88 to $251 in 2000-01) and reviews and appeals are being scheduled by the Board within legislative time frames. Changes in mental health treatment practices and a reduction in the duration of treatment for involuntary inpatients have meant that, currently, nearly 70 per cent of involuntary patients are released from their involuntary status without coming before the Board for a hearing, unless they appeal. The implications of this are unclear for the Board’s objective of seeking to balance the needs of individuals to receive treatment, the loss of freedom that the individual experiences when they are treated involuntarily, and the interests of the community.

1.15 Over time, the Department has made considerable progress in the redistribution of funds to AMHSs on a more equitable basis, but discrepancies remain. We endorse the Department’s strategy to examine and revise the resource allocation model.

1.16 The current set of mental health measures and key performance indicators (KPIs) do not provide sufficient information to management and the Government to measure the effectiveness of the services being delivered. Most of the current measures and KPIs are not tied to departmental objectives and relate to service delivery (i.e. outputs) rather than consumer outcomes. The current set of measures and indicators is also limited in its coverage of mental health services.

AUDIT FINDINGS

Responding to people in psychiatric crisis

1.17 Between 1997 and 2001, the total number of registered Area Mental Health Service (AMHS) consumers increased by 20 per cent. There has also been a 36 per cent increase in registered client contacts during the same period. (para. 3.5)

1.18 Data on the prevalence of mental disorders in the community indicate that 2 to 3 per cent of the adult population may have a severe mental disorder. If the figure of 3 per cent is compared with the number of registered service users, up to one-third of people with a mental disorder meeting the AMHS target group may not be receiving treatment from AMHS. In Victoria, this translates to about 40 000 people who may be accessing alternative mental health services, such as general practitioners and private psychiatrists. (para. 3.7)

1.19 The relationship between presenting problem and service response suggest that the majority of consumers rates as urgent receive an AMHS service response. During interviews with consumers and carers, a common source of complaint was that consumers and carers believed that AMHSs provided services based on a person’s diagnosis as opposed to their level of need and disability. AMHSs noted the difficulties they face in providing services to a broad target group, in an environment of limited resources. (paras 3.56 and 3.58)

1.20 A recent Statewide review of adult acute psychiatric inpatient services reported that it is becoming increasingly difficult for consumers to gain access to acute inpatient beds in some areas. Victoria has emphasised community-based services providing a higher proportion of its services and beds in community settings than other States. The overall number of designated acute psychiatric inpatient beds in Victoria has remained relatively constant since 1996, despite a 20 per cent increase in overall service demand. Victoria now has 21.8 acute beds per 100 000 adults; 2.6 beds below the national average. (para. 3.73)

1.21 Increasing service demand and associated levels of unmet demand are resulting in service access difficulties for many consumers, early discharge from hospital, and increased burden on family and carers. These outcomes increase the likelihood of future unplanned re-admissions.(para. 3.10)

1.22 Based on our limited observations during the audit and data provided by the Royal Melbourne Hospital Emergency Department (ED), consumers presenting to EDs with serious mental health problems often experience lengthy waiting periods. Physical infrastructure in hospital EDs were inadequate for the assessment and treatment of mental health consumers. (para. 3.48)

1.23 Our review of 935 clinical files found that 31 per cent of 583 consumers treated in the community did not receive either an individual service plan or an inpatient management plan. None of the 402 individual service plans examined addressed all of the criteria as recommended by Department of Human Services’ clinical guidelines. (para. 3.96)

1.24 Patients and carers benefit greatly from receiving appropriate information about the nature, causes and treatment of mental disorders. “Psycho-education” is generally considered an integral part of the treatment and recovery process and is emphasised in the national standards. Interviews with consumers and carers and the file audits indicate that consumers of public mental health services are not routinely receiving psycho-educational services from the public mental health system or being referred to the private system for these services. (para. 100 and 3.101)

1.25 Thirty per cent of hospital discharge plans reviewed included no evidence that consumers had been linked into appropriate community-based services for ongoing treatment following inpatient discharge. Similarly, 48 per cent of all case closure plans (or service exit plans) reviewed had no documentation indicating that consumers had been linked into appropriate services for ongoing care in the community. (para. 3.114)

Carers and families

1.26 In order to be effective, public mental health services must take into account the important role of carers and families, and be responsive to their needs where possible. This has been recognised in the second National Mental Health Plan and in the Department’s own policies and framework for service delivery. (para. 4.31)

1.27 The amount of time carers spend looking after the person with a mental illness, ranges from under 10 hours per week to more than 50. (para. 4.14) Carers most frequently sought help from public mental health service psychiatrists and case managers, but found the services provided by carer associations and support groups more helpful. Some of these associations and support groups receive funding from the Department. (para. 4.17)

1.28 As part of a survey undertaken for this audit, carers were asked to rate the impact of the person’s mental disorder on themselves and their family. The majority of carers reported that they and their families experienced a number of negative consequences in terms of their level of happiness, their leisure time, their physical and mental health, their personal relationships, and their standard of living. This evidence is consistent with the findings of a national survey of carers that was undertaken in 1999 by the Carers Association of Australia. (para. 4.26)

Rights of involuntary patients

1.29 Since its establishment in 1987, the operational efficiency of the Mental Health Review Board has improved significantly. The Board’s workload has increased by more than 600 per cent since 1987-88, while the cost per completed case has fallen from $472 in 1987-88 to $251 in 2000-01. (para. 5.14)

1.30 Under the Mental Health Act 1986 the Mental Health Review Board is required to review all involuntary patients within 8 weeks of their admission, hear appeals from patients who wish to be discharged from their involuntary status, review all involuntary patients at least every 12 months, and review every decision to extend a community treatment order. The audit found that while the vast majority of these reviews and appeals are being scheduled for hearing in a manner consistent with legislative time frames, there is an opportunity to further improve the administration of hearing processes. (paras 5.58 and 5.59)

1.31 During 2001, patients were not present at 38 per cent of hearings. In 31 per cent of hearings, the patient gave prior notice that they did not wish to participate, and in 7 per cent of hearings the patient simply did not attend on the day. This pattern was similar for both metropolitan and regional venues. (para. 5.33)

1.32 During 2001, 51.6 per cent of involuntary patients were discharged within the first 2 weeks of admission and were not, therefore, listed for initial review by the Board. Of the 6 372 initial reviews listed for hearing in 2001, 37.8 per cent of patients listed for hearing were discharged from their involuntary status prior to the hearing date. Thus, the majority of involuntary patients (nearly 70 per cent) do not appear before the Board to have their situation independently reviewed, unless they appeal. (para. 5.37)

1.33 The Board determined 5 690 cases in 2001; with 6.2 per cent resulting in the patient being discharged from their involuntary status and 93.8 per cent were confirmed as meeting the criteria for continued involuntary status. The rate of discharge has remained relatively constant since 1987, and is similar for both metropolitan and regional patients. (para. 5.49)

1.34 Patients with legal representation were more likely to have their involuntary status discharged. Further research will be required to clarify the cause of this result. It is not known whether the legally represented patients were less unwell than those not legally represented. (para. 5.50)

Funding of Area Mental Health Services

1.35 Over the period 1992-93 to 1997-98, mental health spending on stand-alone hospitals reduced by $137.6 million (74 per cent) and $157.5 million was directed to the development of replacement services, mainly in community-based settings. (para. 6.4)

1.36 Across areas, funding aligns fairly well with the model-determined share of funding based on the Department’s weighted population formula. However, discrepancies remain. The biggest discrepancies are in the inner metropolitan area (which receives more than its model-determined share) and the central-east of Melbourne (which receives less than its model-determined share). The Department advises that redistribution of funding to match weighted population share is achieved through the allocation of new funding. (para. 6.8)

Measuring the effectiveness of mental health services

1.37 In the 2002-03 State Budget, $588.5 million was allocated to Mental Health outputs. This represents 7 per cent of total recurrent funding to the Department of Human Services and 11 per cent of the Health budget. The major output targets for mental health services for 2002-03 include:

• 17 400 inpatient separations provided to people with a mental illness;

• 55 000 continuing clients in clinical community care;

• 9 124 clients receiving Psychiatric Disability Support Services; and

• 19 521 training hours of clinical staff. (para. 7.5)

1.38 The Department’s set of mental health key performance indicators and performance measures are not sufficiently comprehensive to provide management with the necessary information to measure the effectiveness of mental health services. In particular, they do not provide any indicators of service demand. In the absence of a broader set of indicators, many AMHSs have developed their own management reports. While the 4 performance indicators currently used by the Department should be retained, improved performance information could enhance the management effectiveness of the sector. (para. 7.18)

RECOMMENDATIONS

RESPONSE provided by Department of Human Services

The Department of Human Services (DHS) welcomes the report and acknowledges the pressures under which the system operates. Increasing demand and work force shortages in the public sector, particularly of mental health nurses and psychiatrists, were the drivers for the New Directions in Victoria’s Mental Health Services policy released in September 2002.

DHS notes the audit took place over a 12 month period during which time DHS was also consulting consumers, carers, clinicians and service providers. The New Directions for Victoria’s Mental Health Services document identifies the gaps in the system and action taken to date to improve public Mental Health services, and outlines a vision for the next 5 years. Key stakeholders all contributed substantially to the New Directions document. DHS has, as part of its strategy, commenced addressing many of the issues identified by audit. New services are being developed between hospitals and the community, step-up/step-down services, improved methods for handling complaints and an extensive recruitment and retention campaign for mental health nurses, and new training and education initiatives are underway.

In response to growing demand for mental health services the Department is expanding existing services and has commenced the development of a demand management strategy which is one of the strategies in the New Directions for Victoria’s Mental Health Services document This strategy will address service system pressure points through service improvement and diversion initiatives. It will also focus on the further development of need reduction strategies, including strategies in relation to prevention and early intervention.

Audit Objectives and Scope

The Department accepts that there was insufficient and poor documentation on client files in some of the services audited. Documentation of service provision clearly requires improvement.

The Office of the Chief Psychiatrist Clinical Reviews have made recommendations to services about appropriate Duty contact documentation including documentation of risk levels, actions taken, and other relevant information.

Office of the Chief Psychiatrist Clinical Reviews have also made recommendations that all non-accepted referrals be subject to a secondary check regarding eligibility decisions by the clinical team or another senior clinician, and signed off. This is gradually being implemented in services.

The Office of the Chief Psychiatrist will provide further education sessions on documentation to area mental health services, and will develop guidelines for clinical documentation.

Further comment by the Auditor-General

The audit found significant gaps in the completion of key service delivery processes, based on a file review, interviews with key stakeholders, surveys of consumers and carers, and analysis of system data. Audit is encouraged by the Department’s commitment to improve documentation.

RESPONSE provided by Department of Human Services - continued

24 Hour Face to Face Assessment by Area Mental Health Service Clinicians
While welcoming the report, DHS has some issues about the way in which the audit has assessed performance on urgent cases. The National Mental Health Standards were agreed by Ministers in December 1996. Audit did not assess the services on their implementation of these Standards. Instead, audit assessed whether the response of the Area Mental Health Service (AMHS) met the standard set by audit of a “face-to-face” assessment by an AMHS clinician within 24 hours. This is not required by existing standards and DHS considers that measuring against a new standard does not present a fair view of system performance.

The relevant National Standard 11.2.12, page 30 of the National Standards document states: “The MHS has a system which ensures that the initial assessment of an urgent referral is commenced within one hour of initial contact and the initial assessment of a non-urgent referral commences within 24 hours of initial contact. Notes and examples: professional assessment of urgency, the assessment process may be commenced with initial history taking, risk assessment, needs assessment over the telephone by an appropriately qualified mental health professional”.

The Standard does not require face-to-face assessment by AMHSs within 24 hours. For urgent referrals, commencing the process by telephone is appropriate. If, as in some cases, face-to-face assessment is judged as clinically required it does not always have to be by an AMHS Clinician but may be able to occur in consultation or liaison with another service provider, or there may be a referral to another service provider.

Victorian public mental health services are a key provider of services to a proportion of consumers with serious mental illness through provision of clinical inpatient and community services and psychiatric disability support services. The Audit does not adequately take into account that the private and broader health sectors also play a key role in the treatment of consumers with serious mental illness and serious mental disorders. The target group defined on page 12 of the Introduction is not just the target group for Area Mental Health Services.

As part of Victoria’s commitment to continuous quality improvement in mental health services, and in the exercise of the Chief Psychiatrist’s responsibilities under the Mental Health Act 1986 (Victoria), the Department’s Mental Health Branch has developed a protocol for conducting Clinical Reviews of Mental Health Services.

The Clinical Review Program commenced in November 1997 and is in the final year of a 5-year cycle. In this period, it has reviewed 20 of the 21 AMHSs, and considered around 2 000 patient files and over 500 duty contact sheets. In examining service response to incoming referrals, the Clinical Reviews have found that the majority of referrals deemed urgent receive an appropriate response in a timely manner.

The Auditor-General’s findings do not accord with the findings of the Office of the Chief Psychiatrist. DHS will ask the Office of the Chief Psychiatrist to undertake another review of a sample of files to ensure that the existing system of assurance is reliable. The discrepancy between the Auditor-General’s finding and those of the Chief Psychiatrist, is in our view, due to differences in methodology and the difference between the Auditor-General standard and that adopted by DHS.

Further comment by the Auditor-General

Audit sought to provide information to Parliament and the community on the timeliness of response to people with a mental illness who are in crisis. The Department is concerned with our use of data from our file review which recorded the proportion of urgent cases seen within 24 hours.

There are 2 parts of the national standard which are relevant. Standard 11.2.12 and the related Notes and Examples quoted above. This standard is confusing. The Notes and Example relate to the professional assessment of urgency which is relevant to the Entry or Duty phase. However, Standard 11.2.12 provides guidance for the initial assessment once the consumer has already been rated as urgent. Standard 11.3 – Assessment and Review provides further guidance on the nature of that initial assessment: “Wherever possible, the MHS conducts face-to-face assessments but may use telephone and video technologies where this is not possible due to distance or the consumer’s preference”. This Standard (11.3.13) clearly relates to the Intake assessment.

Reflecting the above, we examined the files to establish first that an assessment of urgency had been made at Entry (sometimes referred to as Duty or triage) and then that those who had been assessed as urgent had received a face-to-face assessment in the stated time frame.

In the context of the above, the audit examined 935 case files in 6 AMHS, documenting the 2 steps in the process from presentation or referral to the service:

• Duty (sometimes called entry or triage). At this point, an initial assessment of risk and urgency is made. The Duty worker also takes responsibility for making external referrals where appropriate or, alternatively, organising for an Intake assessment. Due to documentation problems, we could not determine the urgency rating in 53 per cent of presentations. Of the remaining 444 presentations, 34 were excluded because they were referred to other service providers and not to be treated by the AMHS and 60 were excluded because they were not rated as urgent. The remaining 350 presentations of people in crisis were rated by an AMHS clinician as requiring urgent assistance. It is these urgent presentations for whom we sought information on the timeliness of response. Unfortunately, timeliness of response could only be calculated for 191 presentations; and

• Intake (sometimes called initial assessment). The next step in the process is an intake assessment. As pointed out by the Department, the national standard says these assessments should be commenced within one hour for urgent cases and within 24 hours for non-urgent cases. Recording was poor, so we were only able to report in days. For the 191 urgent presentations, we found that 65 per cent (or 124 people in crisis) did not receive a face-to-face assessment by an AMHS clinician within 24 hours. After 7 days, there were still 25 per cent (or 47) of them who had not received a face-to-face intake assessment by an AMHS clinician. While specific information was not recorded, our reviewers found little evidence on file that these urgent presentations were being treated by someone else (since those with documented referral had already been excluded) and only very few cases of telephone contact with the person.

We welcome an assessment by the Office of the Chief Psychiatrist to assure the Department of the timeliness of service provision in AMHSs.

Data Issues

Audit makes a statements about changes in service delivery over time, but provides no actual, trend or comparative data to support these.

There are, for example, claims about increases in additional unplanned inpatient re-admissions, longer response times, reduction in the quality of care and access rationing with no supporting data. Data collections in these areas do not currently exist so these claims cannot be tested. DHS is putting in place systems to collect data on unplanned patient re-admissions and response times.

RESPONSE provided by Department of Human Services - continued

Audit, in paragraph 2.34, states that there has been a reduction in work force. Audit is using data from the National Mental Health Report that includes domestic and administrative staff. Use of data for clinical staff which is also in the National Mental Health report is a better indicator of service levels and shows a 14 per cent increase in clinical staff from 1997-99 to 1999-2000.

Carers

The Victorian New Directions for Victoria’s Mental Health Services document acknowledges carer contributions and the increased carer burden. The development of formal systems for carer involvement in mental health policy and planning, at both the Government and local service levels, will continue to be a high priority.

Funding

The Department welcomes Audit acknowledgement that DHS has made considerable progress in distributing funds to Area Mental Health Services on a more equitable basis. DHS has updated the weighted population formula with more recent data and commissioned a qualitative review of its methodology.

Performance indicators

The Measures and KPIs are deliberately output focussed as they are used for aggregate reporting to Government on output performance. These indicators are not intended to be used for service management or outcomes measurement purposes.

The Department agrees with the audit that outcome measures are important. As acknowledged by Audit, Victoria was the first jurisdiction to trial the use of routine outcome measurement, commencing with a small number of pilot agencies in the mid-1990s, and subsequent development of policy and training materials. An Information Development Agreement with the Commonwealth was signed in October 2001, providing $9.2 million to establish information infrastructure to support a national focus on service effectiveness, including the comprehensive introduction of outcome measures. Victoria leads the way in the implementation of outcome measurement in Australia, and when fully implemented in all States and Territories, Australia is expected to be the first country in the world to have implemented outcome measurement across both the public and private sectors.

Victoria is aiming to have 70 per cent of AMHSs reporting outcomes data by June 2003.

In addition to implementing outcome measurement across AMHSs, the Department will consider the measures and key performance indicators put forward by audit.

Future Response

There are pressures on the system. There are increasing numbers of people with mental health problems and growth in the numbers of people seeking, and being provided with, specialist services by AMHSs. This growth in demand is acknowledged and is being addressed.

In September 2002, the Victorian Government launched New Directions for Victoria’s Mental Health Services. The New Directions report sets out overall directions and strategies for the development of mental health services and programs over the next 5 years. It outlines how the mental health service system will be better positioned to respond to existing and future demand for care by building on the strengths of the current system, developing an appropriate mix and level of service, and implementing new and innovative approaches to consumer needs. Some of the key initiatives which are being implemented include:

• more acute beds and expanded community mental health services to better manage growing demand;

• new and innovative “sub-acute” and intensive treatment and support models of service delivery to improve responsiveness to consumer needs;

• tailored responses for young consumers to reduce the impact of mental illness on their future development and opportunities;

• integrated responses to the growing group of people with both mental illness and substance abuse problems;

• a comprehensive plan for the mental health work force focussing on its future development and management; and

• strengthening and extending consumer and carer participation and support.

The actions and initiatives described in the New Directions document also include a strong focus on future long-term planning and structural improvements to manage demand for mental health services and build the capacity of the service system. As implementation occurs, the State will be in a position to further extend these initiatives and improve services for Victorians with mental health problems.

The 6 key directions for the next 5 years are:

• expanding service capacity;

• creating new service options;

• extending prevention and early Intervention;

• building a strong and skilled workforce;

• strengthening consumer participation; and

• improving carer participation and support.

RESPONSE provided by Barwon Mental Health Service

Thank you for the opportunity to be involved in this audit and I trust that Victorian Parliamentarians will be interested in its content and conclusion. We look forward to benefiting from any initiatives from government to improve and enhance services to people who suffer from a mental illness. [Specific comments provided in relevant Part.]

RESPONSE provided by St Vincent’s Mental Health Service

Thank you for the opportunity to respond to the performance audit report. As it is now 6 years since major reform of Victorian mental health services took place, it is timely to examine the performance of mental health services, particularly in response to people in crisis.

While the report identifies many shortfalls in the delivery of mental health services for people in crisis, it fails to comment on the significant improvements in the mental health service system over the last ten years. It should be noted that until 1994, there were only a small number of Crisis Assessment and Treatment Services operating in Victoria, and community services had very limited outreach capacity. After 1994, these services were developed across Victoria. In 1999, these services were funded to provide services on a 24 hour basis. Until 1995, there was no comprehensive case-management system that aimed to identify a primary contact for each person accessing mental health services. Acute inpatient services have also undergone major reform – with purpose-built facilities co-located with general hospitals replacing old and decrepit buildings in institutional settings.

Consumers, carers and staff with whom we have had contact acknowledge that although the current system is not perfect, it is a great improvement on what was there before. Victoria is the only Australian state to have comprehensive mental health services across all areas. At the recent Australian and New Zealand Mental Health Services Conference, the achievements in Victoria stood out, whether it was in relation to consumer and carer participation, development of cross-sector services such as dual diagnosis initiatives, the integration with the general health sector or the provision of non-government psychosocial rehabilitation services, or the availability of a 24 hour response to psychiatric crises.

The report notes the increased demand on mental health services, and highlights the need of mental health services to respond to all people with high mental health needs, not only those with psychotic disorders. The Primary Mental Health Service initiative has shown promise in expanding the capacity of the service system, but further resources will be needed, plus education and practice change, to ensure that mental health services are able to respond adequately to people in crisis.

We agree that documentation of response to people in crisis could be considerably improved, and that there needs to be a system-wide approach to assessment of urgency and risk.