PART 2

INTRODUCTION

THE MENTAL HEALTH OF VICTORIANS

2.1 This audit involves an examination of Victoria’s public mental health services, with a focus on the response to adults in psychiatric crisis. The audit also examines the responsiveness of the mental health system to the needs of those who care for a person with a mental disorder; the protection of patient rights through the Mental Health Review Board; mental health funding and resource allocation; and the framework for monitoring performance in the public mental health system. A full description of the audit’s objectives, scope and methodology is provided in Appendix A of this report.

2.2 In 2001, about 55 000 Victorians received services from the public mental health service system. Recent estimates from the Victorian Burden of Disease study suggest that mental disorders are a leading cause of disability, accounting for 26 per cent of the non-fatal health burden in Victoria. The 1997 National Mental Health and Well Being survey reported that 18 per cent of Australians (about 2.4 million people) have a mental disorder. Demand for services is increasing, and this trend is likely to continue over the next 5 years¹.

2.3 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. Overall quality of life is reported as lower, and most experience difficulty functioning effectively in the community and maintaining healthy relationships. People with psychotic disorders (such as schizophrenia) often experience considerable difficulty coping with everyday tasks, maintaining social relationships and occupational functioning.

2.4 The provision of mental health services to the community involves the Commonwealth, private service providers and the public mental health system. The Commonwealth provides funding to State and Territory Governments to support the ongoing reform of mental health service delivery systems. It also provides funding for income and disability support through a range of Commonwealth programs for people with mental disorders. Private psychiatrists and general practitioners are funded by the Commonwealth through the Medicare Benefits Schedule, and psychiatric medications through Pharmaceutical Benefits subsidies.

2.5 General practitioners and private psychiatrists have an important role to play in providing services. In 1999-2000, an estimated 10 per cent of general practice encounters involved the management of at least one mental health-related problem. In 1999-2000, private hospitals accounted for a third of mental health treatment episodes, and public hospitals the remainder.

2.6 Victorian public mental health services have a key role in responding to people with serious mental illness and assisting their family or carers, particularly during a psychiatric crisis. It is, therefore, important that public mental health services offer timely and appropriate care to Victorians in need of such services.

What is a mental disorder?

2.7 A “mental disorder” is defined as a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual, which is associated with distress, disability or with a significantly increased risk of suffering death, pain, disability or a significant loss of freedom². This definition encompasses disorders which affect a number of people in the community, including depression and anxiety disorders, and less common psychotic disorders, such as schizophrenia.

Who uses public mental health services in Victoria?

2.8 The public mental health service system responds to people of all ages who have mental health problems requiring specialist expertise. The 1994 Framework for Mental Health Service Delivery in Victoria defines the “target group” for adult public mental health services as follows:

“… people with serious mental illness and/or an associated significant level of psychosocial disability. This includes clients suffering from functional psychoses, both acute and persistent, severe mood and eating disorders, or with severe anxiety disorders, as well as those who present with situational crises which may lead to self harm or inappropriate behaviour directed towards others. People with severe personality disorder whose behaviour places themselves or others at risk of harm are included in the target group”. (page 26)

2.9 In 1999, 32 350 adults, 9 628 children and adolescents, and 8 176 aged persons were registered with a Victorian public mental health service. Chart 2A illustrates the diagnostic breakdown of people receiving services.

chart 2a
relative proportions of victorians registered
with mental health services, by diagnosis,
1998 to 1999

Note: Data for 2001-02 could not be provided by the Department of Human Services.

Source: Department of Human Services, 2002.

2.10 Chart 2A illustrates that public mental health services in Victoria respond to a relatively large number of people with psychotic disorders. While psychotic disorders accounted for 39 per cent of service registrations in 1998-99, their rate of occurrence in the community is relatively low (estimated at around one per cent of the population). People with more common (or “high prevalence”) disorders, such as depression and anxiety, tend to be referred to primary health care providers general practitioners or private practitioners for ongoing treatment. Table 2B shows the estimated prevalence of mental disorders among Australian adults in the community.

table 2B
Estimated prevalence of mental disorders
among Australian adults

(a) Includes eating, adjustment and somatoform disorders.
Note: A person may have more than one disorder, therefore, the components when added may be greater than 100 per cent.
Sources: Australian Bureau of Statistics (1997), Mental Health and Wellbeing Profile of Adults, Australia; Commonwealth Department of Health and Aged Care (1999), and People living with psychotic illness: an Australian study 1997-1998.

Economic and social cost of mental disorders

Victorian Burden of Disease study

2.11 Mental disorders have a significant economic and social impact on the wider community. The Victorian Burden of Disease study provides the first comprehensive assessment of the health status of the Victorian population and quantifies the contribution to the “burden of disease” of mortality, disability, impairment, illness and injury arising from 176 diseases, injuries and risk factors. The study was conducted in 1996 and published in 1999.

2.12 The study reported that mental disorders are the leading cause of disability in Victoria. Depression was reported as the leading cause of non-fatal burden in both men and women, accounting for 8 per cent of the total burden.

2.13 Chart 2C illustrates the burden in lost years due to disability in both men and women. Mental disorders and neurological conditions contribute most to the total non-fatal burden, accounting for two-fifths in men and almost half in women.

CHART 2C
non-fatal disability burden,
by sex and broad disease grouping, victoria, 1996

Source: Victorian Burden of Disease Study, 1999.

Suicide

2.14 Australia has one of the highest suicide rates in the Western world. While the overall suicide rate has not changed significantly, youth suicide in Victoria has increased over the past 40 years, and is now the third largest cause of death among young people aged 15 to 24 years, behind motor vehicle accidents and cancer-related illness. Between 1990 and 2000, 6 049 Victorians aged 15 or more committed suicide. Victoria’s suicide death rate averaged around 12 per 100 000 population and the suicide was lower than the national average in each of these 11 years.

2.15 The Victorian Suicide Prevention Taskforce Report (1997) indicated that up to 90 per cent of young people who commit suicide suffer from a mental disorder, such as depression or schizophrenia. Consistent with national standards, public mental health services have a responsibility to respond to people at risk of serious self-harm or harm to others during or following a psychiatric crisis, whether this is due to a first or recurring episode of acute mental disorder.

Co-morbidity

2.16 National surveys consistently report a relationship between mental disorder and substance abuse, particularly among people with psychosis. Harmful substance use was reported by 49 per cent of people with a psychotic disorder in the 1999 national psychosis survey³. Moreover, 25 per cent of the total sample reported a lifetime history of cannabis abuse.

2.17 Australian Health (2000), a report by the Australian Institute of Health and Welfare, highlights the high levels of physical problems associated with mental illness. Fifty per cent of people diagnosed with depression in one survey reported a physical illness or condition requiring treatment. The report also noted that people with a mood disorder were 2 to 3 times more likely to have a heart attack during their life compared with the general population. Cigarette smoking rates are 2 to 4 times higher among people with a mental disorder, and approximately 80 per cent of people with psychosis are regular smokers⁴.

Unemployment

2.18 People with mental disorders are significantly more likely to be unemployed than people with good mental health. The 1997 National Mental Health and Well Being survey estimated that 36 per cent of males and 32 per cent of females with a mental disorder were unemployed during the 12 months prior to the survey. In a study of people with psychotic disorders, 72 per cent of people surveyed were unemployed, highlighting the considerable occupational burden of psychotic disorders⁵.

Housing and accommodation

2.19 A high proportion of people with mental health problems use public housing. The Commonwealth’s 1999 national study of people with psychotic disorders reported that 45 per cent of those surveyed were reliant on accommodation in institutions, hostels, group homes, supported housing or crisis shelters. Eighty-five per cent of the sample were reliant on welfare benefits. Obtaining safe, affordable housing was difficult or beyond the financial capacity of most people surveyed.

2.20 The national study also noted that for most people with a mental disorder, the provision of stable, affordable accommodation is a necessary prerequisite for recovery. Access to secure housing with appropriate support services may provide an environment conducive to recovery which reduces the likelihood of recurring mental illness and future need for mental health services.

Police and ambulance services

2.21 Police and ambulance services are increasingly involved in responding to mental health crises. Between January 2000 and December 2001, the Victorian Metropolitan Ambulance Service (MAS) responded to 2 047 people with mental health concerns⁶. The MAS reports a 27 per cent increase in the emergency transport of people with a mental illness between 1996 and 2000. A new set of mental health response protocols for the MAS⁷ was issued in February 2001.

2.22 Similarly, in 2001, Victoria Police responded to 843 incidents where mental health concerns were reported⁸. This represents a 33 per cent increase from the previous year. Victoria Police have recently introduced new guidelines for responding to people with mental disorders which aim to improve the appropriateness of response.

NATIONAL MENTAL HEALTH STRATEGY

2.23 In 1992, State and Commonwealth Governments in Australia endorsed the National Mental Health Policy and Strategy, foreshadowing reform of how services were provided to people affected by a mental disorder. The endorsement covered both a national direction and a framework for governments to work together to change a system that was widely acknowledged as inadequate and long neglected by policy makers⁹.

2.24 Broadly, the aims of the National Mental Health Policy and Strategy were to:

• promote the mental health of the Australian community and, where possible, prevent the development of mental health problems and mental disorders;

• reduce the impact of mental disorders on individuals, families and the community; and

• assure the rights of people with mental disorders.

2.25 The Strategy was articulated in 4 major policy documents: the National Mental Health Policy, the First National Mental Health Plan 1992; the Mental Health Statement of Rights and Responsibilities; and the Medicare Agreements 1993-98. In combination, these documents outlined a new approach to mental health service delivery, and the action plan for implementing the proposed changes over the first 5 years of the Strategy.

Key service reforms under the National Mental Health Strategy

Mainstreaming and integration

2.26 From 1993, a number of key reforms to public mental health services began across Australia. Reform included relocating acute psychiatric beds from isolated psychiatric institutions to general hospitals. This was accompanied by the closure of several large stand-alone psychiatric institutions. The rationale behind these changes was a belief that stigma could be reduced and care improved by bringing the delivery and management of specialist mental health services within the general health system – a process referred to as “mainstreaming”.

2.27 A further element of reform was the integration of mental health services across inpatient and community-based service components. Integration of services aims to provide continuity of care so clients can move between service elements as their needs change and receive the most appropriate service response at any time.

Expansion of community-based services

2.28 The National Mental Health Strategy also sought to change the mix of services available, replacing stand-alone psychiatric institutions with a comprehensive range of inpatient, residential, community treatment and community support services. A community-oriented approach to the provision of mental health services was promoted. Commonwealth Reform and Incentive Funds were made available to support States and Territories in developing community-based mental health treatment services, and community residential and support facilities. The range of community-based mental health services was to include:

• assessment, treatment and rehabilitation services provided on a clinic, domiciliary or outreach basis for people affected by mental disorder;

• community-based residential units staffed by mental health professionals on a 24-hour basis that provide rehabilitation for people with long-term disabilities associated with severe mental disorder; and

• services provided by not-for-profit non-government organisations, funded by governments to provide residential and non-residential rehabilitation programs and outreach support services for people with a psychiatric disability arising from a mental disorder.

Funding changes

2.29 Total recurrent expenditure on specialised mental health services in Australia increased by an average of 6.0 per cent per year between 1992-93 and 1999-2000¹⁰. This was almost double the corresponding Victorian increase of an average of 3.3 per cent. Funds allocated to mental health services in Victoria are projected to grow by an average of 8.6 per cent from 1999-2000 to 2002-03¹¹. These funds in the 2002-03 Budget amounted to $588.5 million, or 7 per cent of total recurrent funding in the Department of Human Services and 11 per cent of the Health budget¹².

2.30 As shown in Chart 2D, per capita expenditure on mental health services in Victoria has remained above the national average since 1992, however, the gap has reduced in recent years. Issues concerning regional funding to public mental health services in Victoria are described in Part 6 of this report.

Chart 2D
mental health expenditure, victoria and australia
(RECURRENT PER CAPITA EXPENDITURE, $ IN CONSTANT PRICES)

Source: Victorian Auditor-General’s Office, based on Commonwealth Department of Health and Aged Care, National Mental Health Report 2001, draft appendices.

2.31 The shift towards community-based care was accomplished through a significant redirection of Commonwealth and State Government funding. Chart 2E highlights the redistribution of funding in Victoria during this time. Between 1992 and 2000, per capita funding to stand-alone psychiatric hospitals and total inpatient services decreased by 860 and 125 per cent, respectively. During the same period, per capita funding to co-located psychiatric units, community residential services, ambulatory services and non-government organisations increased by 45, 185, 80, and 226 per cent, respectively.

Chart 2E
specialised mental health services
expenditure, per capita, victoria, 1992 TO 2000

Source: Commonwealth Mental Health Branch.

2.32 A breakdown of total mental health expenditure in Victoria by age group is shown in Table 2F. This illustrates the large proportion of annual funding allocated to adult mental health services (the focus of this audit), compared with child and adolescent and aged care services. The Department of Human Services advises that this allocation is consistent with the distribution recommended in its 1996 framework.

TABLE 2F
mental health service expenditure
by age group, Victoria, 2001-02

(a) Adult specialist and Statewide services.

Source: Department of Human Services, 2002.

Service linkages

2.33 Recognising the complex needs of mental health consumers, formal linkages with other service systems, including drug and alcohol, housing, ambulance and emergency services, were also encouraged under the National Mental Health Strategy. The Strategy also promoted shared care arrangements between general practitioners, private psychiatrists and public mental health services.

Work force changes

2.34 As Victorian services have become mainstreamed with a shift towards community-based treatment, human resources have been redirected accordingly. Full-time inpatient staff reduced by 45 per cent between 1993-94 and 1999-2000, and ambulatory and community residential staff increased by 42 and 212 per cent, respectively. Overall, the total number of full-time equivalent staff employed in specialist mental health services decreased by 7 per cent during the same period¹³.

National standards in service delivery

2.35 As part of the National Mental Health Strategy, a set of National Mental Health Standards were developed and endorsed by all States and Territories in 1997. These Standards were developed as a guide to service enhancement and continuous quality improvement. The Standards relate to human rights, links with other services, access and response issues, and care and treatment of mental health patients and their carers.

Evaluation of the First National Mental Health Strategy

2.36 The agreement of all Australian and State Governments to the National Mental Health Strategy included a commitment to evaluate both the progress and outcomes of the various initiatives. An evaluation was undertaken and published in 1997¹⁴.

2.37 Overall, the evaluation concluded that while the range and quality of services available in Australia had improved substantially over those that existed in 1992, many service delivery objectives had not been attained and consumer treatment and carer support had been adversely affected as a consequence.

Second National Mental Health Plan
(1998 to 2003)

2.38 In July 1998, a Second National Mental Health Plan was endorsed by all Australian Health Ministers. The Plan provided a 5-year (1998 to 2003) framework for activity at national and State levels, building upon the achievements of the First National Mental Health Plan (1993 to 1998).

2.39 The Second Plan emphasised 4 additional areas of reform:

• mental health promotion and prevention - increasing community awareness and acceptance of mental disorders through advertising campaigns;

• partnerships in service reform and delivery - improving links both within mental health service systems and between the mental health service system and other systems;

• monitoring service quality and effectiveness - development of outcome measures and agreement on accreditation of services against national standards for mental health services by June 2003; and

• illness prevention and early intervention.

Progress under the Second National Mental Health Plan

2.40 In November 2001, a mid-term review of the Second National Mental Health Plan was conducted¹⁵. That review supported the principles of the Plan, noting that “the Plan reflects exemplary mental health policy leadership”. However, a number of concerns were raised in relation to the Plan’s delivery at a national and Statewide level. The review concluded that:

• The response received during a mental health crisis is often slow and unreliable;

• Crisis services were not consistently responsive to people with early signs of relapse, indicating that the current capacity for crisis response services is only sufficient to intervene for those in the most severe crisis situations;

• Despite the provision of early intervention teams, some people with severely disabling mental health problems are unable to access treatment and care unless they are in an advanced state of illness;

• Australia is experiencing a serious, if not critical, mental health work force shortage in numbers, with an uneven distribution of clinicians of all disciplines;

• Service “silos” exist whereas seamless systems are needed to co-ordinate delivery of mental health, housing, education, disability and family services;

• With one exception (WA), mental health and substance abuse services are separated, which makes operational co-ordination of services for people with these disorders difficult;

• Mental health services in rural and remote areas are generally recognised to be less available than those in metropolitan areas. Concerns were raised in terms of difficulties in recruiting and maintaining staff, and that crisis assessment services do not operate fully out of hours;

• The application and monitoring of service standards, while acknowledged as important, have so far been introduced in an ad-hoc manner; and

• Despite the increasing government focus on mental health services over the past decade, many needs remain, especially for people with the more common disorders and people living in rural or remote areas.

MENTAL HEALTH SERVICES IN VICTORIA

Legislative framework

2.41 The Mental Health Act 1986 provides the legislative framework which guides and regulates the provision of services to people with a mental disorder in Victoria. The Act indicates that services must operate so that people who are mentally ill receive the best possible care and treatment in the least restrictive environment, enabling care and treatment to be provided effectively.

2.42 Clear directions are provided under the Act for the Department of Human Services about the way services should be delivered. Services must:

• provide standards and conditions of care and treatment for persons who are mentally ill which are, in all possible respects, at least equal to those provided for persons suffering from other forms of illness;

• take into account the religious, cultural and language needs of persons who are mentally ill;

• minimise the adverse effects of mental illness in the community;

• be comprehensive, accessible and acceptable;

• be designed to reduce the incidence of mental illness in the community;

• provide for intervention at an early stage of mental illness; and

• support the patient in the community and co-ordinate with other community services.

2.43 Importantly, the Act also defines the rules and safeguards which must apply when care is provided to any person on an involuntary basis, including the laws governing the operation of the Mental Health Review Board which determines appeal and review decisions for involuntary treatment.

Roles and responsibilities

Department of Human Services

2.44 The process of mainstreaming mental health services emphasised the different roles and responsibilities of the purchaser (the Department) and service providers (the Area Mental Health Service). The Department defines its role as:

• development of policy and guidelines which support government decisions;

• regional and Statewide service planning;

• purchasing service provision for each of the service areas; and

• monitoring the quality and quantity of services provided to people in each area.

2.45 The Mental Health Act 1986 defines the legislative requirements of the Departmental Secretary. Specific requirements relevant to the present audit include the following:

• Service planning and co-ordination: to facilitate the planning, co-ordination and development of a comprehensive and accessible range of mental health services which are integrated within an identifiable mental health program and which are provided within the organisational arrangements for general health services;

• Continuity of care: to promote the development of systems and services which improve continuity of treatment and care, and which enhance access to general health, mental health and welfare services;

• Service monitoring and evaluation: to oversee and monitor standards of mental health services;

• Consumer rights (information): to facilitate the provision of appropriate and comprehensive information and education to people receiving treatment for a mental disorder in an approved mental health service and other people with a mental disorder about their mental disorder, its treatment and the services available to meet their needs;

• Education: to facilitate education, assistance and consultation programs about mental disorders for primary health care workers in order to help them understand, manage and appropriately refer people with a mental disorder;

• Carer support: to support the development of services which assist carers and promote self-help and advocacy for people with a mental disorder and to facilitate the provision of information, education and support to carers and advocates; and

• Early intervention: to provide for intervention at an early stage of mental disorder.

Area Mental Health Services

2.46 In 1994, the Victorian Government initiated a major redevelopment of the public mental health service system¹⁶. Consistent with the national shift towards community-based treatment, all stand-alone psychiatric institutions would eventually be closed, and existing beds relocated to new local facilities across the State.

Area Mental Health Services provide assistance for people across the lifespan.

2.47 Mental health services in Victoria are now provided through 21 local Area Mental Health Services (AMHSs). All areas have access to a range of inpatient, community residential and ambulatory services. All clinical inpatient services have been mainstreamed into general hospitals and each AMHSs provides a range of general services and, in some cases, specialist Statewide services. Service delivery within AMHS across Victoria includes:

• 21 Adult Area Mental Health Services, which assess and treat adults (aged 16 to 64) with serious mental illness;

• 17¹⁷ Aged Persons Mental Health Services, which assess and treat older people (aged 65 and over); and

• Child and Adolescent Mental Health Services, which assess and treat children and adolescents (up to 18 years of age) who have a serious mental disturbance or who are known to be at risk of such disturbance.

2.48 Each AMHS is responsible for the timely and appropriate provision of services consistent with national standards and State legislation. Chart 2G shows the core service elements of each AMHS, as well as specialist services provided on a regional or Statewide basis.

chart 2G
Victorian Mental Health Service System and budget figures,
2001- 02

Source: Department of Human Services, 2002.

Service elements of the adult system (the focus of this audit) are described below.

Crisis Assessment and Treatment (CAT) Services

2.49 CAT services are often the “first port of call” for people experiencing a mental health crisis. CAT services provide assessment services in hospital emergency departments, screen all inpatient admissions, and provide community assessment and intervention for people with an acute psychiatric condition. CAT services assess whether an inpatient admission is required and can provide intensive home treatment and support as an alternative. They should be available 24 hours a day, 7 days a week¹⁸. CAT services also provide support to other mental health and general health practitioners, and the consumer’s family or carers.

Mobile Support and Treatment (MST) Services

2.50 MST services provide intensive long-term community treatment and support on an outreach basis to consumers with substantial and prolonged severe mental disorder and associated disability. Most commonly, the consumer will have schizophrenia, however, the specific focus of the MST service are consumers who are especially prone to relapse and those at high risk of requiring hospitalisation. MST services have a high staff-to-client ratio and operate on an extended hours basis, 7 days a week

Continuing Care, Clinical and Consultancy Services

2.51 Each AMHS has one or more local community mental health clinics providing assessment, acute and continuing treatment for consumers and consultancy for local general practitioners and other health and welfare agencies. These community mental health clinics provide an initial assessment service for people requesting assistance where a CAT service response is not required. Ongoing case management is usually provided by clinicians from these clinics. The focus is on people with serious mental illness who require treatment, monitoring and continuing support, as well as more specialist individual, group and family therapy programs.

2.52 The most intensive residential rehabilitation services are community care units (CCUs) which are managed by AMHSs. These are designed for people with serious mental disorders and marked disabilities, some of whom would have been patients of extended care wards of former psychiatric institutions. CCUs are purpose-built residential units in community settings which provide a home-like environment and 24-hour clinical support. The CCU provides an opportunity for community living and enhanced quality of life for residents.

Residential and Non-Residential Rehabilitation Services

2.53 Rehabilitation services are an essential component of a comprehensive mental health service system. Rehabilitation aims to assist people with psychiatric disabilities regain the social and practical skills for everyday living in the community, and is provided through both residential and non-residential services.

2.54 Residential rehabilitation services are generally managed by non-government organisations. Residents stay for periods ranging from a few months up to a year while re-establishing themselves in the community. Many of these residential rehabilitation services target young people and were established with government funding from the 1997 Victorian Suicide Prevention Initiatives.

2.55 Non-government organisations also provide non-residential rehabilitation services using both center-based and outreach approaches. These services aim to promote and maintain recovery and improve quality of life, complementing the assessment and treatment functions of clinical services. Day programs focus on strengthening the capacity of people with psychiatric disabilities to live successfully in the community. In addition, through the provision of rehabilitation on an outreach basis, psychiatric disability support services enable people with different levels of psychiatric disability to obtain and maintain public housing.

Acute Inpatient Services

2.56 Acute inpatient services are co-located with general hospitals and provide short-term assessment and treatment for people whose acute mental disorder cannot be safely managed in the community. Treatment is provided on a voluntary or involuntary basis during the acute phase of mental illness until the person has recovered sufficiently for treatment to be provided in a community-based setting.

Secure/Extended Care Inpatient Services

2.57 Secure/extended care inpatient services provide intensive treatment and support for people with unremitting and severe symptoms, together with associated significant behavioral disturbance that inhibits their capacity to live in the community. These services are generally provided on a regional basis due to the relatively small number of people in this category.

Statewide and Regional Specialist Services

2.58 Adult mental health services also include a range of specialist Statewide and regional services such as regional mother-baby units for mothers with a mental disorder and the Statewide forensic mental health service. Additional services established during the 1993 to 1998 period of service redevelopment included Statewide services for people with severe and borderline personality disorders, and for people with intellectual disability who have a mental disorder. In addition, a program to improve assessment and treatment for people with mental illness and substance abuse was successfully piloted in the western Melbourne metropolitan area. This has now been replicated in other regions.

Recent service initiatives in Victoria

2.59 The Victorian Government identified a broad direction for mental health in its 1999 pre-election policy statement. The policy identified the following areas as requiring further development or improvement:

• access to services, particularly psychiatric inpatient services and after-hours services for people experiencing a mental health crisis;

• consumer and carer participation in treatment and discharge planning;

• mental health care in the “primary” health sector;

• training and development of the mental health work force;

• accommodation and support for people with mental illness; and

• early detection and treatment of mental disorders.

2.60 These broad principles were recently reinforced when the Department launched New Directions for Victoria’s Mental Health Services: The Next Five Years on 4 September, 2002. Some of the recent initiatives described in this statement include:

• Primary Mental Health Teams to assist local primary care providers in recognising and treating common mental disorders, particularly depression;

• the Statewide Dual Diagnosis Program, for training and secondary consultation to AMHS staff working with clients who have a mental disorder and drug-use problem;

• an additional 30 acute inpatient beds and piloting of 30 sub-acute beds Statewide;

• new carer support programs;

• additional homelessness outreach services, as a response to the growing number of homeless people with a serious mental disorder; and

• re-engaging the work force through a comprehensive strategy that aims to attract and retain skilled people in all mental health disciplines.

Mental health service delivery in Victoria:
the current situation

2.61 The Second National Mental Health Plan’s emphasis on mental health promotion and prevention, partnerships in service provision, and effective service delivery, are strategies which set the scene for improving the mental health of the nation. Similarly, the proposed initiatives described in the Department’s New Directions statement, aim to address some of the identified gaps in service provision.

2.62 Despite the establishment of new service initiatives over the past 5 years, recent Statewide reviews indicate significant gaps in service provision, and ongoing problems with current mental health service delivery practices in Victoria¹⁹. The reviews indicate that service access to both inpatient and community-based services is becoming increasingly difficult for many consumers. Quality of treatment, discharge practices, protection of patient rights, and consumer participation in service delivery have been raised as areas of concern by many consumers and carers, and stakeholders involved in service provision.

2.63 At present, only the public mental health system is available 24 hours a day, 7 days a week to respond to the needs of people in psychiatric crisis. A delayed or inappropriate service response increases the risk of self-harm, suicide and violence, placing both the consumer and the public at potential risk. Recent service reviews and submissions from consumer and carers groups indicate this is an important area of service provision requiring urgent attention.

2.64 This audit undertook a comprehensive examination of public adult mental health services in Victoria. The following Parts of the report comment on:

• the response to people in psychiatric crises (Part 3);

• the responsiveness of the mental health system to the needs of carers (Part 4);

• the protection of patient rights through the Mental Health Review Board (Part 5);

• mental health funding and resource allocation (Part 6); and

• the framework for monitoring performance in the public mental health system (Part 7).

¹ Victorian Department of Human Services, Victorian Burden of Disease study (1999).

² American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, (1980) 4^th Edition, Washington DC.

³ Commonwealth Department of Health and Aged Care, People Living with a Psychotic Illness: An Australian Study 1997-1998 (1999).

⁴ J. de Leon, F.J Diaz, T. Roger, D. Browne & Dinsmore, Initiation of daily smoking and nicotine dependence in schizophrenia and mood disorders. Schizophrenia Research, (2002), v.56, pp. 47-54.

⁵ Commonwealth Department of Health and Aged Care, People Living with a Psychotic Illness: An Australian Study 1997-1998, (1999).

⁶ Figures provided by the Metropolitan Ambulance Service (MAS). Includes all psychiatric patients transported by MAS (emergency or non-emergency).

⁷ Victorian Department of Human Services, Ambulance Transport of People with a Mental Illness.(2002).

⁸ Figures based on a subjective judgement of the reporting officer as to the presence of a “mental handicap”.

⁹ Commonwealth Department of Health and Family Services, Evaluation of the National Mental Health Strategy – Final Report (1997).

¹⁰ Commonwealth Department of Health and Aged Care, National Mental Health Report, Draft appendices (2001).

¹¹ Government of Victoria, 2002-03 Budget, Budget Paper No. 3, Statement No. 2 and earlier Budget papers

¹² Victorian Department of Human Services, Victorian Public Hospitals and Mental Health Services Policy and Funding Guidelines (2002-2003).

¹³ Commonwealth Department of Health and Ageing, National Mental Health Report, Draft appendices (2001).

¹⁴ Commonwealth Department of Health and Family Services, Evaluation of the National Mental Health Strategy (1997).

¹⁵ Commonwealth Department of Health and Ageing, International Mid-Term Review of the Second National Mental Health Plan for Australia (2001).

¹⁶ Victorian Department of Human Services, Victoria’s Mental Health Service: The Framework for Service Delivery (1994).

¹⁷ Service regions for child, adolescent and aged person’s mental health services cover larger regions of Victoria than adult services.

¹⁸ Victorian Department of Human Services, Mental Health services: Psychiatric crisis assessment and treatment services – guidelines for service provision (1994).

¹⁹ Victorian Department of Human Services, Revitalising Acute Inpatient Services: report of the review of adult acute inpatient mental health services (2000).