Royal commission hears potential solutions for ‘broken’ mental health system

Evidence pointing to a lack of access and understanding across the system has permeated hearings to date, leading to calls for more community-based preventive help.
 
Friday’s hearing was told of volunteers and community leaders who have taken it upon themselves to provide help where it is currently lacking.
 
One example is school principal Greg McMahon, who is trying to combat disadvantage by providing a range of programs and life classes for both students and parents, including some with a focus on mental health.
 
Mr McMahon told the Royal Commission into Victoria’s Mental Health System that the mental health needs at his school were significant, but his program, which eventually came to be known as ‘Our Place,’ had effectively engaged students and aided parents.
 
‘We’ve got significant trauma in the school … The Department of Human Services are basically at the school every day for some reason: whether it’s case management or picking up clients or other things,’ Mr McMahon said.
 
‘One of the greatest barriers for any parents who have come through, certainly trauma, is that they are asked to tell their story, repeat their story over and over again to different organisations, different services, and ultimately they get sick of it.
 
‘As a college, as a community hub, we’ve basically taken on the idea that we never turn a person away.’
 
Other initiatives, including wearable technology for the elderly designed to track conversation and alert family members of carers to social isolation, were also on show.
 
However, despite the positivity, the majority of the hearings have been punctuated by nearly three weeks of shocking statistics and harrowing testimony, as the flaws precipitating the state’s mental health crisis have been laid bare.
 
Acute prioritised over community intervention
Stories of desperate people being turned away from health services due to a shortage of resources have been commonplace, while a gradual shift towards prioritising acute hospital care over community has pushed emergency services to breaking point.
 
Despite spending $1.5 billion on clinical care in the last State Budget, Victoria is suffering from a major shortage of mental health beds, and the commission was also told the risk-based assessment process for deciding which patients to admit effectively excludes 70% of people seeking help.
 
Those who do qualify for help are often discharged prematurely, in many cases without regard to their circumstances, and sometimes with dire consequences. The same shortage has also seen hospitals regularly breach a rule dictating that patients should not stay in the emergency department (ED) for more than 24 hours, with some patients left waiting for up to five days in EDs for treatment.
 
Aside from access issues, mental health advocate Janet Meagher told one of the commission’s early hearings that patients are also experiencing discrimination, and said there are ‘shocking’ contrasts between treatments for mental health services and other medical interventions.
 
‘Currently, we are just surviving. I beg you for a change,’ she said.
 
‘We need health professionals who encourage and support and enable, not just people who make us conform to medication regimes.’
 
Problems within the hospital and acute care system have been exacerbated by ‘insecure and inadequate’ funding for community health services, which have also been plagued by fragmentation and a lack of planning for population growth.
 
Only $99 million was given to community support services last year, pushing wait times for public psychology services out to months, and leading to major gaps in current treatment, especially early engagement for children and those with a moderate illness.
 
The crisis has seen an explosion in the number of acute cases statewide, evidenced by a 90% increase in the number of police incidents involving a ‘psychiatric crisis’ in the four years to 2018.
 
Victoria police attended around 43,000 events relating to a psychiatric crisis, or suicide attempt or threat in 2017–18, and attended a mental health call out approximately every 12 minutes. The commission also heard that 14,000 people were detained by police for treatment under the Mental Health Act in 2016–17, an increase of almost 170% over six years.
 
Assistant Commissioner Glenn Weir told the inquiry the rise in people presenting with mental health disorders was ‘undeniable’ and the increased number of call outs had affected morale.
 
‘Our people do get frustrated because we aren’t trained clinicians,’ he said.
 
‘We get frustrated by what seems to be a revolving door around people who are apprehended, taken, assessed and then, three or four days later, we’re back again.’
 
Rural and minority communities particularly vulnerable
Rural areas of Victoria are arguably facing even larger issues. A lack of specialist care means patients often need to travel hours to access services, leading to above average rates of mental illness.
 
At a public hearing in Maryborough, it was revealed more than one in five Central Goldfields residents had experienced high or very high degrees of psychological distress, while one quarter of the population had had a self-inflicted injury or died by suicide.
 
Of the 12,000 people covered by the Maryborough Health Service, around 1000 are on mental health plans, including 250 for children or adolescents.
 
Minority communities have also been badly affected.
 
Under the current regime, Aboriginal and Torres Strait Islander people are three times more likely than the general population to experience high levels of psychological distress and twice as likely to be hospitalised for mental health issues. Young people who identify as LGBTQI are between five and 11 times more likely to attempt suicide.
 
The Victorian Government has already committed to adopting all of the inquiry’s recommendations, and its own submission has outlined a ‘radical overhaul’ via a ‘stepped’ model of care.
 
The ‘person-centred’ mental health care system would be designed to make movement between high and low-intensity services more fluid according to patient need, and allow treatment at any stage of illness – including before a person becomes unwell.
 
‘In short, we don’t actually have a system at the moment, what we have is a system of unconnected services that creates huge gaps that far too many people fall in,’ Mental Health Minister Martin Foley said.
 
‘The stepped-care model is about building better connections between mental health services so people don’t fall through the cracks, like too many do right now.’
 
The government submission also includes a plan to expand community-based services in an effort to reduce the need for acute inpatient beds and help people with higher needs to access appropriate care.
 
GPs uniquely placed to help
Senior Lecturer in the Department of General Practice at the University of Melbourne, Dr Caroline Johnson, told the commission GPs are uniquely placed to deal with mental health patients, including for people who aren’t willing or able to access other services.
 
‘A GP can be focussed on early intervention, on the relationship with the patient, and supporting the patient over a long period of time. This is quite different to a hospital scenario, where people go for a specific period of treatment and after a period of time, they are often discharged with a “you’re better” sticker,’ she said.
 
She also said GPs should been seen as a central part of the solution, but require more support to navigate ‘overly complex and poorly connected’ mental health care pathways.
 
‘I believe that a GP needs to be trained in navigating and understanding pathways of care. It’s not acceptable that someone is just having a stab in the dark because the last thing the patient tried didn’t work,’ she said.
 
‘GPs struggle to keep up with all the different silos of care coming and going around them … I think the system could offer better incentives to enable the GP to offer and the patient to choose the intervention best supported by evidence.’
 
Clinical Director of Mental Health at Werribee Mercy Hospital, Associate Professor Dean Stevenson told the hearings that the current model of community care has broken down and that funding would need to be at least doubled to adequately provide services.
 
‘As the funding became tighter and demand grew, we were no longer able to meet the demand,’ he said.
 
‘There’s not sufficient early relapse prevention in the community, which then feeds into a higher demand at the acute end of services … it becomes a vicious cycle.’
 
The final week of hearings began today, with a focus on suicide prevention and prioritisation and governance of mental health services.

mental health royal commission Victoria