INTRODUCTION

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 about 8.6 per cent per year since 1999-2000.

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.

While mental health services may be provided by general practitioners and private psychiatrists, the public mental health system must be available for involuntary patients and is the major source of 24-hour crisis assessment and treatment.

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.

WHAT DID THE AUDIT EXAMINE?

The objectives of this audit were to determine:

1. whether Area Mental Health Services (AMHSs) were providing timely and appropriate services to adults (16 to 64 years) who experienced a mental health crisis, or who were at significant risk of experiencing a crisis;

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

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

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

5. 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.

The audit’s scope included examination of the Department of Human Services, the Mental Health Review Board and 6 of Victoria’s 21 AMHSs.

In assessing the timeliness and appropriateness of service response, the audit examined consumer referral records, clinical files and Statewide databases. Interviews with consumers and carers were also conducted. The audit accepted the clinical judgement of AMHS practitioners, including their assessment of risk and urgency of patient needs.

AUDIT CONCLUSIONS

1. We examined 191 case files of people with a severe mental illness who had presented to an AMHS and were rated as “urgent” by an AMHS clinician. People who were referred to private practitioners for assessment and treatment were not included in the sample. Assuming our sample of 191 case files had been correctly assessed as urgent by the 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. Moreover, 25 per cent of urgent cases did not receive an initial face-to-face assessment for 7 or more days. There is presently debate between the Department, AMHSs and mental health practitioners regarding the appropriate standard against which timeliness of service response during a psychiatric crisis should be measured.

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), and limited involvement of consumers and carers; and

• there were significant gaps in the completion of individual service plans and case closure plans.

2. 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.

3. Reviews and appeals are being scheduled by the Mental Health Review Board within legislative time frames, and its operational efficiency has improved significantly. 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.

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

5. 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 rather than consumer outcomes. The current set of measures and indicators is limited in its coverage of mental health services.

KEY FINDINGS

Response to people in psychiatric crisis

Between 1997 and 2001, the total number of registered AMHS consumers increased by 20 per cent. However, 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.

Our review of clinical files found that 31 per cent of consumers treated in the community did not receive either an individual service plan or an inpatient management plan. In addition, 30 per cent of hospital discharge plans reviewed included no evidence that consumers had been linked into appropriate community-based services for ongoing treatment following discharge.

Carers and families

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.

Rights of involuntary patients

The Mental Health Review 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 confirmed as meeting the criteria for continued involuntary status. The rate of discharge has remained relatively constant since 1987.

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.

Funding of Area Mental Health Services

Funding provided to adult public AMHSs aligns fairly well with each area’s intended level of funding as determined by the Department’s funding formula. However, discrepancies remain. The biggest discrepancies are in the inner metropolitan area (which receives more than its formula-determined share) and the central-east of Melbourne (which receives less than its formula-determined share). The Department advises that redistribution of funding to match weighted population share is achieved through the allocation of new funding.

Measuring the effectiveness of mental health services

The Department’s set of mental health KPIs and performance measures are not sufficiently comprehensive to provide management with the necessary information to measure the effectiveness of mental health services. 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.

Recommendations

The audit makes 21 recommendations. These relate to the timeliness and appropriateness of services response by AMHSs; services for carers; patient rights; and key performance indicators.