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Disability Rights: Not for Service - Report: Part 6_4

Not for Service: Experiences of injustice and despair in mental health care in Australia

PART SIX: ANALYSIS OF SUBMISSIONS AND FORUMS AGAINST THE NATIONAL STANDARDS FOR MENTAL HEALTH SERVICES

6.4 SOUTH AUSTRALIA

ANALYSIS OF SUBMISSIONS AND CONSULTATIONS FROM SOUTH AUSTRALIA AGAINST THE NATIONAL STANDARDS FOR MENTAL HEALTH SERVICES

In summary, information presented in this section was gathered from 31 submissions (see Appendix 8.3.4) and presentations made at community forums attended by approximately 120 people (see Appendix 8.1). A draft copy of this report was sent to the Premier and Minister for Health for comment. A partial response was received on 9 May 2005 and a further response on 12 May 2005 - both well after the extended deadline. An analysis of the response from the South Australian Government (reproduced in Appendix 8.4.4) and an overall review of mental health service delivery in South Australia is contained in Part 2.7.4.

6.4.1 STANDARD 1: RIGHTS

The rights of people affected by mental disorders and / or mental health problems are upheld by the MHS.

Under this Standard, a submission indicated concern about:

  • the lack of information provided to consumers and their carers;
  • the provision of information about rights; and
  • the rights of carers.

6.4.1.1 Information not provided

Standard 1.8 states: 'The MHS provides consumers and their carers with information about available mental health services, mental disorders, mental health problems and available treatments and support services'. According to one NGO service provider this is not occurring. This is of concern on many levels with regards to consent, choice, the right of a person to know about their illness and the treatment plan (and any side-effects), and for carers to be informed regarding what is and will be happening and how they best support the consumer or access support for themselves.

Very limited written information was provided as "standard consumer information" and access to a more detailed outline of the program was only possible because I was allowed to see a copy and I then shared it with the family.

(NGO Service Provider, South Australia, Submission #233)

The lack of provision of 'standard consumer information' also implies that this consumer and family were not provided with a written or verbal statement of their rights and responsibilities as required by Standard 1.2 (Consumers and their carers are provided with a written and verbal statement of their rights and responsibilities as soon as possible after entering the MHS).

6.4.1.2 Consumers not informed of their rights

Concern was expressed that some consumers were not being provided with a written and verbal statement of their rights and responsibilities as soon as possible after entering the Mental Health Service (Standard 1.2) in a manner that was understandable (Standard 1.3). This was alleged to be occurring with both voluntary and involuntary patients.

Rights are not always explained to voluntary or detained patients.

(Consumer, South Australia, Submission #77)

6.4.1.3 The rights of carers

The Carers Association of South Australia raised concerns about the rights of carers and the need to develop a comprehensive policy on the role and function of carers to define their rights. They argued this was important as much of the care for people with mental illness is provided in the community by families and therefore they need to have some of their rights formally recognised:

The Carers' confusion, stress and tension are exacerbated by failure of the Mental Health system in SA to develop and adopt a comprehensive policy on the role and function of carers in the support of people with a mental illness. This has led to the situation where carers are either ignored by mental health professionals or patronised. At worst, the reaction of the mental health system professionals towards family Carers may be hostile.

(Carers Association of SA, South Australia, Submission #30)

However, it is common for Carers of people with a mental illness to experience a lot of rejection of their caring role, not only from their family member but also from the mental health service system.

(Carers Association of SA, South Australia, Submission #30)

There is a lack of acceptance by the Mental Health System of the Carers legal authority where Enduring Power of Guardianship is held by the Carer. This relates to many of the issues previously highlighted but also relates to:

•  The legal authority needing to be triggered by the incapacity of the consumer and this can be hard to define, assess and / or diagnose.

•  There is no central registration of legal orders such as Enduring Power of Guardianship / Attorney, so therefore the orders are not viewed as valid by professionals.

•  Consumers when unwell can verbally discredit the legal authority held by the Carer, making their legal standing ineffective.

•  Although Carers are mentioned in the Mental Health Legislation it is not elaborated upon and they are therefore not afforded rights within in the Mental Health System despite the fact that of much of the care in the community (in the area of mental health) is provided by families.

(Carers Association of SA, South Australia , Submission #30)

6.4.2 STANDARD 2: SAFETY

The activities and environment of the MHS are safe for consumers, carers, families, staff and the community.

Under this Standard, submissions and presentations indicate concerns about:

  • lack of services for children and youth with behaviour problems; and
  • requirement for staff to be trained to respond appropriately to aggressive and difficult behaviour.

6.4.2.1 Lack of services for children and youth with behaviour problems

According to the notes for Standard 2.2 'safety' is considered in the broadest terms: physical, social, psychological and cultural dimensions. Specifically, Standard 2.2 states: 'Treatment and support offered by the MHS ensures that the consumer is protected from abuse and exploitation'. According to reports received from both a carer and a teacher, children and youth with mental health issues and behaviour problems are being expelled and excluded from school due to their aggressive behaviour. This has been a result of an inability to access services to treat and support these children and youth. This also led to safety concerns for family members, teaching staff and other students at school.

His episodes can be quite abusive and destructive. When I try to help him at this time he threatens me and destroys my property ... I am in fear of what [X] is going to do next, to me, to my property, and most of all to himself. This pattern has been our life since [X] was in Primary School.

(Carer, Mother, South Australia, Submission #195)

I have staff using the expulsion / suspension guidelines to exclude these kids. I have staff being attacked by kids who are on drugs. Because of a lack of services there's nothing left but to exclude these kids. Actually they really need care.

(Teacher, South Australia, Murray Bridge Forum #17)

The additional and unfortunate consequence of failure to access services is the potential to destroy relationships and disruption to education and future employment and life potential for these children and youth.

6.4.2.2 Requirement for staff to be trained to respond appropriately to aggressive and difficult behaviour

Concern was also expressed within treatment settings that nurses are insufficiently trained to 'understand and appropriately and safely respond to aggressive and other difficult behaviours' (Standard 2.4). This results in unnecessary use of force to control situations and jeopardises both the safety of consumers, staff and other consumers in treatment settings.

As a nurse academic and educator, I am aware that it seems that nurses often adopt or are directed to adopt a zero tolerance to aggression and violence, creating an often adversarial stance with patients and thus increasing the possibility of an aggressive episode. There is evidence of this in the recent report (2004) entitled 'Aggression and Violence in Health Care' by the Australian Patient Safety Foundation where patients were confronted by nurses for smoking in the wrong place and due to mismanagement, a nurse was assaulted and the patient punished and placed in seclusion. This is avoidable and unacceptable workplace practice. Patients deserve better care, nurses deserve high quality ongoing education and support to provide them with the skills and knowledge to care for people with difficult behaviours.

(Academic, South Australia, Submission #142)

6.4.3 STANDARD 3: CONSUMER AND CARER PARTICIPATION

Consumers and carers are involved in the planning, implementation and evaluation of the MHS.

Under this Standard, submissions and presentations indicate concerns about:

  • the 'tokenistic' approach to consumer and carer involvement;
  • lack of funding to support consumer and carer participation; and
  • youth participation.

6.4.3.1 Tokenistic approach to consumer and carer involvement

An advocate was so convinced and exasperated with her experiences of consumers and carers not having a voice or role in the 'planning, implementation and evaluation of the MHS' that she stated:

We're at no risk of being threatened for speaking out because we're not being heard at all!

(Advocate, South Australia, Adelaide Forum #15)

This 'lack of involvement' and need was also confirmed by a clinician and another advocate at the same forum.

There is a token approach to consumer and carer participation - tokenistic responses. There is no carer and consumer input. No feedback.

(Clinician, South Australia, Adelaide Forum #11)

According to Standard 3.1 and 3.2 policies and procedures are implemented to 'maximise their roles and involvement' and 'the MHS undertakes and supports a range of activities' that maximise consumer and carer participation.

6.4.3.2 Lack of funding for consumer and carer participation

Related to the lack of meaningful consumer and care participation is the reported lack of funding allocated to support such activities.

There's a need for a rural consultation in areas like Port Augusta ... There's also a need for consumers, carers etc to be heard and to be supported with funding.

(Advocate, South Australia, Adelaide Forum #15)

I've been involved in the Murray Mallee Consumer Advisory Group for 6-7 years. The first 3 years we funded ourselves. At the moment we are providing a wide service. Responsible for providing education, networking. We do all of this on a budget of $4,000 per year from the Murray Mallee Health Service. Our funding hasn't increased in the last four years.

(Consumer & Advocate, South Australia, Murray Bridge Forum #8)

Consumers and carers continue to be largely denied effective participation in both their personal treatment and in the development of effective service delivery systems.

(Clinician, South Australia, Submission #56)

6.4.3.3 Youth participation

Youth Affairs Council of South Australia (YACSA) emphasised the importance of participation by youth in reform processes to maximise health outcomes for children and young people. Mental health, drug and alcohol abuse and access to services (especially for young people in rural, regional and outer metropolitan areas) were noted as critical issues for consultation with young people:

YACSA welcomes a health reform process with a human rights perspective that identifies children and young people as a priority population group, and a reform process with a focus on community participation, as determined by the Generational Health Review. In general, health services for young people in South Australia are increasingly inclusive with regard to youth participation in service planning and delivery. YACSA notes that this should be encouraged, and that the need remains for youth health advisory mechanisms such as the now defunct Department of Human Services' Youth Views project. Council contends that such an approach is imperative if youth health issues are to be addressed adequately.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

For a number of years, YACSA has recommended that the State Government establish and resource a youth health advisory mechanism to provide advice to the Department of Human Services on policy and strategic issues aimed at maximising health outcomes. With issues of mental health, sexual health, drug and alcohol abuse and access to services (particularly for young people in rural, regional and outer metropolitan South Australia), there is an urgent need to act on the implementation of an appropriate advisory structure to the Minister for Health. Given the Generational Health Review emphasis on regionalisation and community participation, YACSA recommends that the Department of Human Services establish a number of regional Youth Health Advisory Committees in key, strategic locations as determined through the process of decentralising the existing health system. YACSA envisages that the Committees would comprise relevant departmental officers and non-government stakeholders in the youth, community and mental health sectors, as well as representation from young people / consumers. YACSA further recommends that the structure of the Committees be based on the previously successful Youth Views young consumer participation model, with executive support to be provided by existing staff.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

6.4.4 STANDARD 4: PROMOTING COMMUNITY ACCEPTANCE

The MHS promotes community acceptance and the reduction of stigma for people affected by mental disorders and / or mental health problems.

Under this Standard, submissions and presentations indicate concerns about:

  • the high levels of stigma and discrimination still being experienced by people with mental illness;
  • feelings of isolation - rejection by family members and the community;
  • discrimination directed towards children of parents with mental illness;
  • non-acceptance by mental health workers;
  • discrimination in employment; and
  • stigma and stereotypes perpetuated by the media.

Members of the wider community often have inaccurate perceptions of mental illness, leading to further isolation and exclusion of those who are unwell.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

6.4.4.1 High levels of stigma and discrimination

Carers and advocates continue to express concerns about the high level of stigma and ostracism still being experienced by people with mental illness. This would indicate that campaigns and activities to address community acceptance and reduce stigma (Standard 4.1) to date have not been able to turn community attitudes around. As described below, discrimination and lack of community acceptance are key barriers to people with mental illness (and their family members) being able to participate socially, economically and politically in society. Social isolation is often the result.

There is a great stigma being attached to having a mental illness.

(Advocate, South Australia, Adelaide Forum #15)

In the early years of my mental illness I felt self conscious and didn't like to bother my doctor over my mental illness. As time went by I became used to seeing my GP every two weeks without feeling bad about taking up his time on a regular basis. Feeling this way is caused by stigma, devaluing myself and my frustration at taking years to get well.

(Consumer, South Australia, Submission #77)

I have 2 sons who have schizophrenia. [X] (eldest son) had a bad breakdown so we decided we would move to a small community to give him a better chance at life but the stigma here was very bad - when our sons went to the pub for a drink the locals would move away from them.

(Carer, South Australia, Murray Bridge Forum #10)

My elder son and myself are [X]'s sole supports.

(Carer, Mother, South Australia, Submission #279)

Finally I have lost some friends because they could not accept or cope with my mental illness. My new friends have their own mental illness and we meet to socialise and support each other but not in an integrated community way.

(Consumer, South Australia, Submission #77)

In the absence of services to educate the community and services to support integration, family members have reported going to great lengths to assist in this process.

On one occasion when my son was ill he frightened some people in the town and when he was in hospital I put an advertisement in the paper to thank the police for their help but also to try to educate the community that he had received treatment and was not a threat to them. It didn't really help.

(Carer, South Australia, Murray Bridge Forum #10)

I have a family member with a mental illness, and I have encouraged my family member to become involved in the community.

(Carer, Family Member, South Australia, Adelaide Forum #2)

6.4.4.2 Feelings of isolation - rejection by family members and the community

Concern was expressed that stigma and lack of understanding still shape community behaviour and result in the exclusion of people with mental illness in social and workplace settings, and often this behaviour extends to close family members and intimate partners, resulting in relationship breakdown. Standard 4.1 states: 'The MHS works collaboratively with the defined community to initiate and participate in a range of activities designed to promote acceptance of people with mental disorders and / or mental health problems by reducing stigma in the community.' As the following quotes indicate, the need for activities to promote community acceptance not only for the community but for family members as well is critical:

Stigma within the family has been great, as well as in the community. These people need more supported housing and employment options, desperately. There also needs to be more community awareness about mental illness.

(Family member, South Australia, Submission #6)

6.4.4.3 Discrimination directed towards children of parents with mental illness

The extent of the problem with regards to the high level of stigma in South Australia is evidenced by reports of discrimination experienced by children of parents with mental illness:

There is still a stigma in the Mallee against people with a mental illness (especially if they were not born and bred in the Mallee). This also leads to discrimination against the children of parents with a mental illness.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

Because my kids don't get any support, in fact they get teased about having a father who is mentally ill, they then come home and take it out on me; tell me I'm nuts or I'm a loony.

(Consumer, South Australia, Murray Bridge Forum #1)

6.4.4.4 Non-Acceptance by mental health workers

Many consumers and carers also expressed concerns about the lack of acceptance and understanding and what they labelled as discriminatory attitudes shown by some service providers. This is of particular concern given that consumers must come directly into contact with mental health service providers and their views impact directly upon them and their carers:

South Australia has a mental health care system of quick fixes and is staff orientated. In my opinion, mental health services staff are overwhelmingly repulsed by the symptoms of mental illness. What is required is change to a consumer-oriented system that recognises 'fine minds'.

(Consumer, South Australia, Submission #41)

6.4.4.5 Discrimination in employment

Employment and a supportive workplace are seen as key factors in preventing the rapid escalation of mental illness and as being essential in the process of rehabilitation and reintegration into society after a period of mental illness. Standard 4.2 states: 'The MHS provides understandable information to mainstream workers and the defined community about mental disorders and mental health problems'. However, acceptance and understanding of mental illness seem to be lacking in the workplace and discrimination and high levels of stigma are still prevalent in workplace settings:

Employment potential is nil as no one would employ someone who has had a mental illness and been out of the workforce for any length of time such as my ten years so far. The stigma and bias against mentally ill people puts paid to reemployment.

(Consumer, South Australia, Submission #77)

In respect to employment a person can have extended sick leave for a physical ailment or condition but if mentally ill it may be impossible to return to work. A period of mental illness is not looked on favourably by an employer. Applying for work knowing one has been mentally ill for ten years as is the case for me is exceedingly difficult because of stigma. It is assumed I cannot cope with daily life but if I had a broken leg or a bad heart no one would judge me in relation to coping with daily life let alone work. I don't have the right of a job or the right to suffer an illness without bias. Although I do voluntary work at school five days a week for a half hour per day I can't work but if it was possible I might be able to work part time in the future.

(Consumer, South Australia, Submission #77)

6.4.4.6 Stigma and stereotypes perpetuated by the media

Concerns were also raised that any activities by the MHS to reduce stigma in the community must also address education of media personnel to modify their portrayal of people with mental illness and comparative references.

In my opinion there is considerable stigma attached to being mentally ill. The media often reports on certain mentally ill people as being dangerous and frightening. My mentally ill friends and myself are nether dangerous or frightening. Our society expects that people get physically sick but if a person becomes mentally ill for a time they are told unkindly to pull their self together. No understanding is entered into.

(Consumer, South Australia, Submission #77)

6.4.5 STANDARD 5: PRIVACY AND CONFIDENTIALITY

The MHS ensures the privacy and confidentiality of consumers and carers.

Under this Standard, submissions indicated concern about policies and procedures to protect privacy and confidentiality.

6.4.5.1 Staff applying privacy and confidentiality rules without authority or ignore or do not request permission from consumer to share information or involve carers

The Carers Association of South Australia expressed concern that misunderstanding or rigid application of policies and procedures to protect the confidentiality and privacy of consumers is impeding communication between consumers, carers and clinicians in the provision of treatment and the sharing of vital information. These concerns indicate that policies and procedures related to privacy and confidentiality may not be made available to consumers and carers in an understandable language and format (Standard 5.2) and that the mental health system is not encouraging and providing opportunities for consumers to involve others in their care (Standard 5.3). The following quote indicates the level of frustration and despair experienced by carers:

Doctrines of confidentiality and privacy of adult patient information are often interpreted by some professionals and adhered to so strongly within that Carers are intentionally not provided with information about medication, treatment and progress. Also, they are frequently denied linkages with those treating the consumer, even though Carers are expected to support and manage the care of the consumer in the community. The reality is that care provided in the community by family members frequently occurs without recognition from the mental health system, the professionals, or the general health care and primary health care sectors.

(Carers Association of SA, South Australia, Submission #30)

While the following report from one carer suggests that the incident occurred some time ago, it nonetheless demonstrates the negative consequences to relationships that can follow from the total exclusion of carers in the treatment process and failure of carers to be informed (Standard 5.2) and clinicians to understand and apply appropriate privacy and confidentiality policies and procedures:

I was married to a paranoid schizophrenic and did not know ... No Dr. would tell me - ethics, the result was, this "man" totally destroyed my life, and there was not a thing I could do about that legally ... I am still trying to "pick myself up off the floor", but sadly never will.

(Carer, Wife, South Australia, Submission #148)

6.4.6 STANDARD 6: PREVENTION AND MENTAL HEALTH PROMOTION

The MHS works with the defined community in prevention, early detection, early intervention and mental health promotion.

Under this Standard, submissions and presentations indicate concerns about:

  • the lack of focus on prevention in mental health services;
  • lack of services for children and youth; and
  • ack of rehabilitation programs and recovery services.

6.4.6.1 Prevention not a focus of mental health services

The Health and Community Services Network (Murray Mallee Strategic Task Force) made particular mention of the lack of a preventive focus in mental health services in South Australia.

The mental health system still has its focus on acute care at the expense of preventative work and community supports. South Australia spends a lower proportion of its mental health budget on community based supports than other mainland states.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

Indeed, Standard 6.1 states: 'The MHS has policy, resources and plans that support mental health promotion, prevention of mental disorders and mental health problems, early detection and intervention.' Evidence presented in other sections of this Report support the above claim of a lack of community services to intervene early and therefore avert the need for acute care. This focus on the provision of acute care and hospital based services, rather than community based care, is also contradictory to Standard 6.6 'Treatment and support offered by the MHS occur in a community setting in preference to an institutional setting unless there is justifiable reason consistent with the best outcome for the consumer.'

Another aspect of prevention is to assist consumers to identify 'early warning signs of relapse and appropriate action' (Standard 6.7). Evidence was also presented that sufficient information with regards to prevention and mental health problems is not being provided at either a community, individual or carer level.

There is a general lack of awareness and information about mental illness, so that those affected and their friends and family members may not realise that they are becoming unwell.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

6.4.6.2 Lack of services to provide early intervention for youth is a critical problem

...others who unfortunately enter the system from "Boys Homes" because of existing childhood problems seemed trapped in a vicious punishment cycle. They need desperate help for their symptoms, not continual punishment. This 'lockup the too hard basket' attitude makes it almost impossible for people like [X] who have had an abusive childhood combined with mental problems to survive. This is no way to help a person with psychiatric problems who is suicidal. The system seems to be continuing the abuse his father started. He never had any time with out abuse to get his life together.

(Carer, Mother, South Australia, Submission #195)

The availability of services to provide treatment for children and youth with mental illness or mental health problems is critical in terms of averting serious life repercussions. Standards 6.4 ('The MHS has capacity to identify and appropriately respond to the most vulnerable consumers ...') and Standard 6.5 (' .. as early as possible') are clearly not being met according to the concerns expressed in this Report. The concerns expressed here follow concerns previously expressed under Standard 2 (Safety) with reference to protecting the social and psychological wellbeing of children and youth.

We just don't have the resources to support these kids so the schools call the police. Yes we have other avenues, other services but how do we access these - the waiting lists are sometimes 18 months. These kids do not complete their education and they end up in a life of trouble - a horrendous situation - we have the mandate to keep the schools safe - but it's too hard.

(Teacher, South Australia, Murray Bridge Forum #17)

This pattern has been our life since [X] was in Primary School. The cycle has to be broken, as we all deserve a better quality of life ...

(Carer, Mother, South Australia, Submission #195)

6.4.6.3 Lack of rehabilitation programs and recovery services

Rehabilitation programs are acknowledged as a critical step in the reintegration process back into full life after a period of illness and the prevention of relapse for many people with mental illness. Such programs would include living skills programs, respite and social programs. Standard 6.8 states: 'The MHS ensures that the consumer has access to rehabilitation programs which aim to minimise psychiatric disability and prevent relapse'. Concern was expressed by one consumer that he has been unable to access any rehabilitation programs in his area:

Sadly my mental illness has led to me being ill from 1994 to 2004. I am still ill but despite no available rehabilitation program of any sort I try to do voluntary work and do things at home when I can.

(Consumer, South Australia, Submission #77)

Information about mental illness for patients and their families is not forth coming and there is not therapy or rehabilitation in the country such as Murray Bridge in SA. I have spent ten years 1994-2004 doing my own rehabilitation. I was a social worker prior to becoming very mentally ill.

(Consumer, South Australia, Submission #77)

6.4.7 STANDARD 7: CULTURAL AWARENESS

The MHS delivers non-discriminatory treatment and support which are sensitive to the social and cultural values of the consumer and the consumer's family and community.

Under this Standard, submissions and presentations indicate concerns about:

  • the lack of culturally appropriate practices for Indigenous people;
  • lack of culturally appropriate practices for consumers from a non-English speaking background; and
  • the need for culturally appropriate mental health programs for newly arrived young people

6.4.7.1 Lack of culturally appropriate practices for Indigenous people

Evidence was presented which suggests that mental health services have not been planned and delivered in a manner which 'considers the needs and unique factors of social and cultural groups represented in the defined community and involves these groups in the planning and implementation of services' (Standard 7.2).

I'm an Aboriginal Mental Health Worker for the region. Gender issues are a real problem. I've got a case-load of roughly 20, plus their families and then I get new referrals, though many indigenous people do not access services anyway. There's a gender problem too which makes it even harder because some Aboriginal males can not approach female psychiatrists and females won't approach male psychiatrists.

(Clinician, South Australia, Murray Bridge Forum #4)

When indigenous people become unwell they are all put in baskets, they either have a mental illness or a drug and alcohol problem. There's no holistic care. There have been 20 close deaths in my family.

(Anonymous, South Australia, Murray Bridge Forum #15)

However, the Medical Specialists Outreach Assistance Program, funded by the Federal Government, has improved Indigenous services to South Australia's rural and remote communities by providing culturally sensitive mental health services to Aboriginal people in their own communities.

...significant progress that has been made in Sth Aust during the last 2 years in the development of outreach psychiatric services to remote communities in SA under the Medical Specialists Outreach Assistance Program funded by the Federal Govt. They describe the efforts of a group of Adelaide based psychiatrists to provide culturally sensitive mental health services to Aboriginal people in their own communities. The practice model used is that of a Consultation / Liaison model which emphasises the support and upskilling of the local mental health workers. This is a new application of the C-L model. It appears to be reasonably successful in delivering sustainable services to rural and especially remote areas.

(Clinician, South Australia, Submission #274)

6.4.7.2 Lack of culturally appropriate practices for consumers from a non-English speaking background (NESB)

Comments were received which suggests that mental health services have not been planned and delivered in a manner which 'considers the needs and unique factors of social and cultural groups represented in the defined community and involves these groups in the planning and implementation of services' (Standard 7.2). Concern was expressed that even though culturally appropriate practices could be enhanced by a variety of strategies, for example, redesigning job descriptions or employing staff from a variety of backgrounds, organisational support and sufficient resources are not available to enable this to occur. Also, concern was expressed that where strategies had been devised by staff to improve service delivery to consumers from a NESB, proposals have been allegedly ignored:

A recent such example comes from a clinician concerned with access and equity and appropriateness of assessment and treatment methods for persons of diverse linguistic and cultural backgrounds. When past reform initiatives encouraged staff to critically assess their practice and methods with respect to these issues, this, and other clinicians developed some proposals which responded to the National Standards for Mental Health Services, as well as policies and regulations within the State Public Service and specific health services / regions. These proposals were met with contempt, not deserving of even the acknowledgement of being received, in spite of the promise by the current Minister for Health, when in opposition, that, if elected, she would give it serious consideration. All the way down the hierarchy, resistance to suggestions from the "battlefront" were shoved aside and ignored. The response of management has consistently been to stonewall such proposals, to never respond to them, never to reject them on the basis of rational/objective criticism, but to simply ignore them, in spite of these proposals being re-submitted, adjusted to new circumstances and knowledge etc. Over more than 5 years this particular clinician submitted proposals that were essentially costless, but required a minimal reallocation of existing resources, while providing an important qualitative improvement to access and equity and appropriate assessment and treatment approaches.

(Clinician, South Australia, Submission #56)

The marginalisation / denigration takes different forms. One has been the withholding of an appropriate and relevant Job Description for many years, up to the present time, in spite of regular requests from the concerned clinician, many meetings and vague promises. Another form has been the constant verbal character assassinations of the clinician as racist because of [his / her] focus on non-Anglophone immigrants, to [his / her] face and to others, or on the phone. The team leader felt so confident of being at least passively supported by [his / her] superiors that [he / she] eventually lodged a memo to the Service Director accusing the clinician of being racist in [his / her] patient / client selection. Higher management did not respond to this memo, other than making the verbal comment to the clinician that "well there are people who think you should see more English speakers", ignoring the fact that this clinician was the only practicing multilingual staff member of [his / her] service of about 50 staff, and that no other staff member was being asked to see more non-Anglophone patients / clients, in a region where more than one third of the total population is of non-English speaking background, and the rate of referral of persons of non-English speaking backgrounds is in excess of 40% on average over time. This clinician has sought to have the issue of these accusations addressed, but so far unsuccessfully. This is only one example, but it clearly illustrates an organisational culture paralysed by lack of forward looking principles, lack of any ideas of how to put into practice the existing principles of mental health reform contained in the National Standards for Mental Health Services and the mental health reform agenda in general, and an organisation which resorts to tactics of petty repression, bullying etc to maintain the status quo of bureaucratic politics, in a textbook case of sociological / organisational dysfunction.

(Clinician, South Australia, Submission #56)

6.4.7.3 The need for culturally appropriate mental health programs for newly arrived young people

The Youth Affairs Council of South Australia (YACSA) raised concerns about the need for culturally appropriate mental health programs for newly arrived young people:

YACSA's report Out of the Mist: Young People, Emotional Well Being and Life Choices, prepared in conjunction with the Migrant Health Service and the Adelaide Central Community Health Service, contains several recommendations for increasing the effectiveness of mental health services provided to newly-arrived young people. Given the State Government's commitment to culturally appropriate mental health programs, and its pledge through the Platform for Government to ensure that CLDB [Culturally and Linguistically Diverse Background] young people, particularly those who are newly arrived, have access to the services they need. YACSA proposes that a centralised peer support training program be established. This could possibly be in collaboration with TAFE and Multicultural Youth South Australia, to provide trained youth peer support workers from relevant communities to work with community agencies to support newly-arrived young people, from a mental health perspective. Such a project might be modelled on the Cornerstone project currently being run by the Adelaide Central Mission and the Migrant Health Service. Peer support workers would be appropriately trained to work with the relevant issues and would receive ongoing support in their roles.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

6.4.8 STANDARD 8: INTEGRATION

6.4.8.1 Service integration

The MHS is integrated and coordinated to provide a balanced mix of services which ensure continuity of care for the consumer.

People could be placed in the hospital without any mental health workers.

(Clinician, South Australia, Murray Bridge Forum #14)

Under this Standard, submissions and presentations indicate concerns about:

  • problems with continuity between adolescent and adult mental health services;
  • the link between mental health services and general practitioners; and
  • integration with NGO services.
6.4.8.1.1 Problems with continuity between adolescent and adult mental health services

There is a lack of continuity between Child and Adolescent Mental Health Service (CAMHS) and adult mental health services.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

As mentioned previously, not only were concerns raised at the scarcity of services for children and youth, but concerns have also been raised with regards to the continuity of care between adolescent and adult mental health services. Standard 8.1.5 states: 'The MHS has documented policies and procedures which are used to promote continuity of care across programs, sites, other services and lifespan.'

Young people 16-17 come and see us but we do some transitioning to the adult mental health service also. There is a period when there's nothing for young people during this transition.

(Clinician, South Australia, Murray Bridge Forum #14)
6.4.8.1.2 Link between mental health services and general practitioners

Included in Standard 8.1.5 are arrangements for shared care with general practitioners. Varied reports were received with regards to successful shared care arrangements.

GPs sometimes don't listen and a client didn't get admitted because the GP wouldn't support admissions.

(NGO Worker, South Australia, Adelaide Forum #24)

There are some advantages to working in this type of area. There's a community of professionals with the local GP's. I can phone the local GP's for a social admission.

(Clinician, South Australia, Murray Bridge Forum #14)

Some GPs are concerned about taking action (when a person is in need of being collected by the police it is necessary for a doctor to approve an involuntary admission).

(Advocate, South Australia, Adelaide Forum #15)

Notwithstanding the excellent but limited TELEMED and TRIAGE services from Glenside Hospital Campus local GP's can receive consultation with distant psychiatrists to help them manage their local mentally ill patients. Sadly such a service doesn't serve patient's family by enabling them to understand their family member's mental illness; to see and keep in touch with their loved one because of the distance from home to hospital.

(Consumer, South Australia, Submission #77)
6.4.8.1.3 Problems with integration with NGO services

One NGO service provider expressed concern about not being able to work together with other mental health service providers in a coordinated and integrated manner as stated in Standard 8.1.5.

At that further meeting with the Program Director and other family therapist, and after trying to gain clarification on how we could collaborate, I was clearly told that this could not occur and we could only work in "parallel." I was not allowed to discuss my approach with the young person's regular nursing staff and how their work may contribute to the therapeutic process. Although I appreciated that there may be some sensitivities and caution with collaborating with someone outside of their hospital, like myself, there was no flexibility on this matter - something that stands apart from recommended good practice in interagency or private/public sector collaboration.

(NGO Service Provider, South Australia, Submission #233)
6.4.8.2 Integration within the Health System

The MHS develops and maintains links with other health service providers at local, state and national levels to ensure specialised coordinated care and promote community integration for people with mental disorders and / or mental health problems.

Under this Standard, a presentation indicated concern about:

  • the lack of access to health services to meet the physical health needs of people with mental illness.
6.4.8.2.1 Lack of access to services to meet physical health needs

One police officer expressed concern about his / her repeated observation that people with mental illness appear to be having difficulty accessing health services to meet their physical health needs.

There are good things happening but my client groups are the difficult ones. Since the closure of the institutions there has been a large influx of people into this community. But these people need access to other health services for their physical and mental health needs - they often get sent on buses and taxis to Adelaide for care.

(Police Officer, South Australia, Murray Bridge Forum #16)

Mentally ill people can suffer other medical problems such as;

•  arthritis (lithium possibly leaching calcium)

•  sleep apnea (may have triggered epilepsy

•  underactive thyroid (lithium for mood side effect)

•  weight problems (zyprexa major tranquiliser)

•  epilepsy (imbalance in brain biochemistry)

These conditions can require referral to other specialists and in my case only some visit Murray Bridge but others are seen in Adelaide .

(Consumer, South Australia , Submission #77)

6.4.8.3 Integration with other sectors

The MHS develops and maintains links with other sectors at local, state and national levels to ensure specialised coordinated care and promote community integration for people with mental disorders and/or mental health problems.

Under this Standard, submissions and presentations indicate concerns about integrated service with regards to:

  • housing and accommodation;
  • home and community care;
  • police;
  • education;
  • youth;
  • employment and support from Centrelink;
  • youth employment;
  • transport;
  • carer allowance;
  • cost of medication;
  • wards of the state;
  • health in rural and remote areas; and
  • the criminal justice system.

Integration with these, and other sectors, is vital in the whole-of-government approach required to realise the rights of people with mental illness.

The necessity of a whole-of-government approach to specifically care for children who have become wards of the state was also specifically raised through this consultation process.

6.4.8.3.1 Housing

There's a real revolving door syndrome - people get admitted, they get treatment and then they get discharged but because there's no supported accommodation for them they keep coming back into the hospital.

(Clinician, South Australia, Murray Bridge Forum #5)c

Lack of available housing and accommodation options for people with mental illness was repeatedly raised as a critical gap in the process of integrating people with mental illness in the community and improved mental health (see Standard 11.4.B Supported Accommodation). The lack of available housing and accommodation options and the process of deinstitutionalisation and consequent lack of increased community services has also seen an increase in the proportion of people who are homeless who have a mental illness. The housing and accommodation needs of young people were highlighted as major areas of concern by Youth Affairs Council of South Australia.

Housing availability is critical here. Once we get people with a mental illness in our service there's nowhere else for them to go and then we are so stretched we can't respond to the needs of our other clients.

(Accommodation Service Provider, South Australia, Adelaide Forum #4)

Disability supported housing is the only option available, but as there is no interaction with mental health services people with mental disability miss out. There are some disability support mechanisms but they're not funded to support those with a psychiatric disability. We can get them in if they have a dual disability. HACC [Health and Community Care] funding means we can not help people with psychiatric disability only.

(NGO Service Provider, South Australia, Murray Bridge Forum #6)

In his father's opinion neither Governments nor Departments or Courts understand the impact of [X]'s continued homelessness upon his current situation.

(Anonymous, South Australia, Submission #183)

Changes to the Commonwealth State Housing Agreement over recent years have in turn necessitated changes in the provision of public housing in South Australia. YACSA contends that the housing needs of young South Australians must take a priority for the State Government through the South Australian Housing Trust. Public housing plays a fundamental role in the reduction of housing-related poverty and broader social and economic inequalities, offering young people non-discriminatory, affordable housing with security of tenure. In consultation regarding the discussion paper for the upcoming Youth Action Plan, young people noted that it is increasingly difficult to access public housing, and that even if a young person is in need, they are often not in 'enough need' to warrant priority housing. As one young participant noted, "You need to be having a baby to get a house."

(Youth Affairs Council of South Australia, South Australia, Submission #38)

YACSA strongly commends the State Government on its initiation of a ten-year State Housing Plan for South Australia. Council reiterates the Minister for Housing's assertion that young people should be a focus of any initiative that aims to improve housing services for South Australians. In light of this, YACSA recommends that a Youth Housing Strategy comprise a core component of the State Housing Plan, to be developed in conjunction with young people and stakeholders in the youth sector. A Strategy would need to take into consider the particular housing needs of a variety of youth populations, including Indigenous young people, young people leaving care, young people with disabilities including mental health issues, newly arrived young people, etc. Also, while the Plan is statewide in scope, YACSA notes that housing needs vary around South Australia, and needs are not homogenous across all metropolitan areas or all regional areas, a feature that needs to be considered in every stage of the Plan. Features of the Youth Housing Strategy should include but not be limited to:

A commitment to working across Government to improve housing outcomes for young people. The strategy should draw together the Department of Human Services (including the Office for Youth, the South Australian Housing Trust, the Aboriginal Housing Authority, the South Australian Community Housing Authority and Family and Youth Services), the Department of Education and Children's Services, the Department of Further Education, Employment, Science and Technology, the Office of Consumer and Business Affairs and relevant others to establish a service and support framework cognizant of the vital role stable, appropriate housing plays in young people's ability to participate in education, training and employment and maintain a healthy lifestyle.

(Youth Affairs Council of South Australia, South Australia, Submission #38)
6.4.8.3.2 Home and Community Care (HACC)

Mental illness isn't recognised as a disability by HACC services.

(Anonymous, South Australia, Adelaide Forum #10)

The ineligibility of people with mental illness to qualify for HACC services was described by one consumer as an example of direct discrimination. An inability to access HACC services makes it difficult if not impossible for some people with mental illness to continue to choose to live independently.

People with a mental illness are discriminated against. People with other health problems who have been in hospital will get Domestic Care but not so for people with a mental illness - surely they should get the same sort of help.

(Consumer, South Australia, Murray Bridge Forum #7)

In the HACC guidelines there's no acknowledgement of mental illness.

(Social Worker, South Australia, Adelaide Forum #20)

We get our funding through HACC and HACC doesn't include psychiatric disability as a disability. It's very hard to link in with the mental health side of it because there's a very limited number of people to work with and the funding is limited. Dual disability is the biggest problem because it's very difficult to network when everyone is so stressed and stretched.

(NGO Service Provider, South Australia, Murray Bridge Forum #6)
6.4.8.3.3 Police

One police officer raised concerns that collaboration was not occurring to the mutual benefit of all professionals involved in the provision of services to people with mental illness. This feeling of frustration stemmed from a desire to work collaboratively with other professionals to achieve the best possible outcome for consumers given the limited resources and overwhelming demand. Standard 8.3.2 states: 'The MHS supports staff, consumers and carers in their involvement with other agencies wherever possible and appropriate' and Standard 8.3.3 states 'The MHS has formal processes to develop intersectoral links and collaboration.'

We are very frustrated at the coal face. I've charged 1,000's of people. I know when someone is mentally ill. As far as I'm concerned there's no collaboration between professionals in this community. The doctors do not listen to what we say, we don't get any acknowledgement. The doctors won't talk to the nurses or the teachers either.

(Police Officer, South Australia, Murray Bridge Forum #16)
6.4.8.3.4 Education

Similarly, Standards 8.3.2 and 8.3.3 apply to the education sector, including schools, TAFE and universities. Links with the education sector to assist with early identification and early intervention are critical in any set of strategies targeted at prevention. Many presentations were made at forums expressing concern at the inability of schools and TAFEs to identify and support children and adolescents with mental illness or mental health problems. As a link with strategies to reduce youth suicide, this area of service delivery and need for integration is vital.

Our core business is education - we identify children with intellectual disability but not psychiatric disability. We are not funded to support these kids. We can provide inclusive resources but we can't really do it properly. Generally they are just piece-meal packages. I have staff using the expulsion / suspension guidelines to exclude these kids ... Because of a lack of services there's nothing left but to exclude these kids. Actually they really need care.

(Teacher, South Australia, Murray Bridge Forum #17)

There's only 1 FTE [Full-time Equivalent] Disability Coordination Officer for the whole state. We also cover learning difficulties and mental health issues. One of our jobs is to help these kids to get into classes. 1 of our TAFE teachers has 90% of her class with a mental illness.

(Anonymous, South Australia, Adelaide Forum #23)

My position is funded by the Federal Government. I am employed at a 0.5 allocation but my position covers 75% of South Australia.

(Disability Coordinator, South Australia, Adelaide Forum #17)

Alternative education programs have been increasingly recognised by the State Government, schools and the community as an effective way to cater to the needs of young people 'at risk', particularly those excluded or otherwise disconnected from mainstream education. The youth sector has this year begun to report that some young people have been disadvantaged and disengaged as a result of the raised minimum school leaving age, and for this group of young people appropriate alternative education options are imperative. Such alternative education programs are frequently delivered by youth workers, and allow young people to learn at their own pace in supported environments where their educational and personal support needs are met.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

Teachers, students and workers in the public school system report that young people's out-of-school concerns such as mental health and child protection issues are having a broadly negative impact on students' educational outcomes. Further, student populations are diversifying, particularly with an increase of newly-arrived and refugee students who are requiring extra support. Consultation by the Social Inclusion Unit with young people earlier this year regarding school retention issues uncovered a strong recommendation from young people that youth workers be employed in public schools to provide direct support and advocacy to students. The consultation report notes that "young people consulted indicated that they would like to see youth workers in schools. They considered that youth workers were:

•  Impartial about student difficulties

•  Knowledgeable about services

•  Good at creating positive connections with young people

•  Able to liaise between students, teachers, parents,

•  Centrelink, and other relevant parties

•  Able to deliver world and life related topics and to speak engagingly about issues such as disability, discrimination and mental health."

(Youth Affairs Council of South Australia , South Australia , Submission #38)
6.4.8.3.5 Whole-of-government approach for youth

The Youth Affairs Council of South Australia expressed concern about the capacity of services to work with youth with high and complex needs. Coordinated services are seen as essential from an early intervention perspective to halt spiralling negative life consequences which result in homelessness, suicide, entry into the criminal justice system or separation from the family. The need for integration with drug and alcohol initiatives was also seen as critical:

There is a consensus across human service agencies working with homeless young people with high and complex needs that the capacity of agencies to retain and work constructively with these clients needs to be developed. There is also a consensus that there is a need for a residential service that can manage and support these young people in extreme circumstances, as an alternative to hospitalisation or worse.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

The highest risk factors to young peoples' health are related to tobacco and alcohol use. YACSA's Policy Platform acknowledges that there are connections between addictive drug use (including alcohol) and wider issues such as suicide, unemployment, homelessness and social alienation. Other interrelated issues include links with poverty, educational outcomes, and living in outer metropolitan, regional, rural and remote areas ... Young people's health and the problems they experience are diverse and far-reaching. Inequity, and related issues such as poverty, lack of education, housing and access to basic health services, are broad factors that contribute to the health concerns that many young people face.

(Youth Affairs Council of South Australia, South Australia, Submission #38)
6.4.8.3.6 Employment and support from Centrelink

Access to welfare, the supported wage and finding suitable employment are all critical components in the process of social inclusion and living a meaningful life with dignity in the community. However, many concerns were raised regarding difficulties with the current welfare and employment systems and Centrelink. One example of a successful program, funded by the Federal Government, was described.

I just recently obtained a job cleaning houses. The work became very difficult and I could no longer do it. I was given the option of going off the pension because I was earning too much. The problem was if I then could no longer work I'd have no pension either. Luckily I didn't go off the pension because I couldn't keep working.

(Consumer, South Australia, Murray Bridge Forum #12)

I worked as a Job Network case worker of 80 people at Centrelink in Adelaide. 60% of the people I saw had a mental illness but were not on the Disability Pension as nobody would do the paper work to get them on Disability Support Pension. There's no continuity of process and Centrlink's sole purpose is to mask employment jobless rather than help them.

(Anonymous, South Australia, Murray Bridge Forum #13)

We need more opportunities for people with psychiatric disabilities and need to restructure the supported wage system. The system doesn't take into account the episodic nature of mental illness so currently the appraisal system is unfair.

(NGO Service Provider, South Australia, Murray Bridge Forum #11)

We have supportive people here in Centrelink but they are also very under resourced and so the system only benefits people who the can act on their own behalf, not those who are most disabled.

(NGO Service Provider, South Australia, Murray Bridge Forum #11)

It's really hard to meet your mutual obligations on the disability support pension. I know someone who is trying (for the third time) to apply for the disability support pension. The questions regarding physical disability are focused and straightforward but not for psychiatric disability. Some people are too unwell to meet their mutual obligations.

(NGO Service Provider, South Australia, Murray Bridge Forum #11)

One positive program, funded by the Federal Government, indicated the positive outcomes that be achieved for a particularly vulnerable group when integration works successfully. The rights to social and economic participation and living a life with dignity are greatly enhanced by initiatives such as this.

My program is federally funded and has been running for three years. It's aimed at supporting those people with a mental illness & acquired brain injury in the indigenous community - it's a pilot project. After 2 years we had 12 people in employment.

(NGO Service Provider, South Australia, Murray Bridge Forum #11)
6.4.8.3.7 Employment for young people with mental illness or mental health problems

In addition to the general employment concerns raised above, the Youth Affairs Council of South Australia highlighted that specific strategies and initiatives need to be developed to address the issue of barriers to employment for young people with mental illness or mental health problems:

The social cost of unemployment is well-documented; youth unemployment has enormous repercussions for other aspects of young people's lives and decreases their general social health and wellbeing. Four years ago, the report focusing on metropolitan Adelaide entitled Surviving Unemployment: Health Consequences of Youth Unemployment, noted that "labour market programs for young people focus almost exclusively on job skills targeted to meet the needs of employers whilst the health system has primarily focused on acute symptoms such as youth suicide or depression without tackling their structural determinants. The need for integrated multi-disciplinary approaches to tackle the adverse affects of youth unemployment has never been greater." Such a finding is also consistent with the primary health care approach underpinning the Generational Health Review.

(Youth Affairs Council of South Australia, South Australia, Submission #38)
6.4.8.3.8 Transport

Another related but indirect problem with regard to access to services is transport. This concern was raised at one forum indicating that for many consumers, for a myriad of reasons, reliance on public transport and location of services is critical. Collaboration with local transport providers may also be an essential link to be made to enable access to services without discrimination for all consumers.

Lack of transport impacts considerably on access to services.

(Community Health Service worker, South Australia, Murray Bridge Forum #9)
6.4.8.3.9 Wards of the State - need for a whole-of-government approach

Years of neglect and self abuse have taken their affect. The failures of his parents, the across the board systemic failure of governments, departments and services set up to help, the failure of individuals in positions of authority and support, all form part of the complications that go together to make 'X's future existence problematical in the extreme.

(Anonymous, South Australia, Submission #183)

One submission highlighted the need for the Government to adequately care, through a whole-of-government approach, for those children and adolescents placed in the State's care. This anonymous submission claimed that gaps in multiple areas resulted in the deteriorating mental health of one consumer, resulting in serious life consequences.

But whereas for the most part, parents and families don't have the knowledge and resources to take determinative action governments do. Failure to honour the trust which is given it to assist a child in need is a failure of government to maintain the rule of law by which we all in security co-exist.

(Anonymous, South Australia, Submission #183)

With the attention that has now been given in South Australia to inmates of hospitals for the mentally ill and the procedures in place to process them, it is hoped that greater attention will be given to the 'duty of care' responsibilities place upon governments in regard to those given or taken into their care.

(Anonymous, South Australia, Submission #183)
6.4.8.3.10 Carer allowance

With limited access to mental health services, supported accommodation and access to early intervention treatment and support, the burden on families and carers from providing long-term and crisis support is immense. This often impacts on the financial income of the family due to a reduced ability of carers to work. The shifting of care by governments to carers fails to recognise that carers are providing a significant cost-free service that is not being shouldered by the community. Concern was raised with regard to the financial hardship experienced by carers due to the lack of services in the community to provide appropriate treatment and support to people with mental illness and / or mental health problems:

CENTRELINK CARER PAYMENT - The Carer allowance my wife receives for looking after me works out at 70 cents an hour because income [sic] from superannuation and shows how little carers receive. When compared to the average wage Centrelink payments are considerably lower and place real limits on what we can afford. A nurse in hospital looking after me would cost considerably more but hospital admission is need from time to time to give my wife respite.

(Consumer, South Australia, Submission #77)

We need to redefine and reconsider the value we place on caring. What I do know is that carers are not truly valued ... They have no real financial value placed on their work - it is not factored fully into the running of our economy.

(Anonymous, South Australia, Submission #44)
6.4.8.3.11 Cost of medication

With complex issues regarding difficulties in accessing services, especially during the onset of illness and recovery phase, barriers to employment, lack of available supported accommodation or other housing / accommodation options, many consumers experience short and long term financial difficulties. One consumer expressed concern at his inability to afford necessary medication despite holding a pension card:

Although I have a pension card cheaper pharmaceuticals [sic] it still costs a lot regularly especially if like me you have other ailments. They only become free in December when I reach the safety net.

(Consumer, South Australia, Submission #77)
6.4.8.3.12 Health in rural and remote areas - collaboration between State and Federal Governments to improve services in rural and remote areas

As outlined previously in Section 2.8.4, the Medical Specialists Outreach Assistance Program, funded by the Federal Government, is a positive example of how integration and collaboration has worked successfully to enhance mental health services to Indigenous communities living in rural and remote areas of South Australia.

The Medical Specialist Outreach Assistance Programme in South Australia - Improving services to rural and regional areas November 2003 marks the second anniversary of the expansion of visiting psychiatric services to rural South Australia under the Medical Specialist Outreach Assistance Programme (MSOAP) ... The MSOAP-funded psychiatrists now visit 20 towns and communities in rural and remote South Australia. They provide consultation-liaison services that emphasise the upskilling of local general practitioners (GPs) and other health-care workers. Although most of the visiting psychiatrists provide adult services, child psychiatrists now visit four regional centres. The child psychiatry services have been an important development for MSOAP because this is an area of special need and clinician numbers are quite limited. Local child mental health services are highly desired. The disruption to family life is substantial when a child is ill and treatment always involves the inclusion of one or both parents and often other family members. If treatment occurs in the capital city, there is inevitably a major disruption to the family routine, with substantial stress arising from the added costs and social dislocation. Furthermore, the provision of child psychiatric services in the local community facilitates the mobilisation of the community resources for the immediate treatment and ongoing management of the child's condition. The new MSOAP services are likely to improve continuity of care and will help prevent future complications and trauma, both for the patient concerned and the local community. Indigenous South Australians are also beginning to benefit from MSOAP initiatives. (author's emphasis)

(Clinician, South Australia Submission #274)
6.4.8.3.13 Criminal Justice System - collaboration with the Adelaide Magistrates Court to provide services to, and reduce offending by, people with mental illness

As outlined previously in Section 2.8.4, The Magistrates Court Diversion Program is an example of a successful collaborative link to enable the criminal justice system to identify and deal more appropriately with people with mental illness who come before the court and are charged with a summary or minor indictable offence.

The Magistrates Court Diversion Program - Diverting people with mental illness out of the criminal justice system

The pilot Magistrates Court Diversion Program (MCDP), which commenced operation in the Adelaide Magistrates Court in August 1999, was the first 'problem solving' court in Australia designed to deal with offenders with mental impairment ... The impetus for this court came, in part, from South Australia 's then Chief Magistrate who recognised that courts needed to improve their ability to identify and respond to people who had a mental impairment. He noted that people "who did not belong in the criminal justice system" were continually appearing before Magistrates and were "being punished for things which were nothing but a manifestation of their problems" (Alan Moss, 1999).

Aims and Objectives of The Magistrates Court Diversion Program ... The MCDP was designed to 'better ensure that people with a mental impairment who come before the court have access to appropriate interventions that will assist in addressing their offending behaviour' (Justice Strategy Unit, 2000). Overall then, in line with other courts predicated on a therapeutic jurisprudence model, the aim was to use the defendant's contact with the criminal justice system as a vehicle for providing a treatment and support program designed to effect behavioural change.

Description of The Program Persons suspected of a mental impairment and who are charged with a summary or minor indictable offence are referred to the program, generally at the time the charges are laid. Upon referral, the individual is assessed to determine his/her suitability for the program. At that time, the defendant's willingness to participate is also ascertained. Those who do not want to participate are referred back to the normal court process. If a defendant is accepted onto the program, his / her case is then adjourned and an individualised intervention plan is developed which outlines appropriate intervention strategies designed to address the individual's mental impairment issues, any associated factors such as homelessness, and drug and alcohol addiction. For many clients who are already in treatment, the program aims to reinforce and support their continued engagement with their treatment or service provider. For others, it may involve referral to new treatment agencies and services. It should be noted that the court itself does not provide treatment. Instead, the client is referred to existing treatment and service providers ... At the end of the program (which generally extends for between 4 to 6 months), the charges against some defendants are withdrawn by prosecution. In the majority of cases, though, the defendant is sentenced, with his / her progress while on the program taken into account at that point. The majority of defendants are given a good behaviour bond.

Evaluating The Program ... Overall, the results showed a reduction in both the number of participants who were apprehended for offending post-program compared with pre-program, as well as a reduction in the actual number of incidents charged against this group. In particular: There was a significant reduction in the number of participants who offended as well as in the number of incidents detected post-program. Two thirds (66.2%) of program participants did not offend during their post-program year1. At an individual level, just over three quarters (76.4%) of the participants either became non-offenders or were charged with a smaller number of incidents post-program. Although these findings must be treated with caution, they suggest that the program may be having a greater impact on the more serious pre-program offenders ... These findings ... auger well for its future.

(from Skrzypiec, Wundersitz & Mcrostie (2004) Magistrates court diversion program - An analysis of post-program offending - Evaluation findings [Short report])
(Office of Crime Statistics and Research, Attorney-General's Department, Government of South Australia, South Australia Submission #278)

6.4.9 STANDARD 9: SERVICE DEVELOPMENT

The MHS is managed effectively and efficiently to facilitate the delivery of coordinated and integrated services.

The system doesn't reflect the clients' needs - the system is more interested in reflecting KPI's [Key Performance Indicators] / good outcomes / indicators so they don't deal with the difficult ones. These are the ones that are given the bus tickets from other places and they end up here in our community. I know this happens.

(Police Officer, South Australia, Murray Bridge Forum #16)

Under this Standard, submissions and presentations indicate concerns about:

  • the current state of mental health services;
  • the lack of resources and services and the impact of this on clinicians;
  • the lack of services in rural and regional areas;
  • the model of mental health care needs to change as there are insufficient community-based services and there is an inappropriate focus on inpatient and crisis care;
  • lack of consultation with consumers, carers and staff;
  • lack of mechanisms to improve service delivery and accountability;
  • lack of funding;
  • affordability of care - public versus private;
  • problems with funding arrangements for service providers;
  • lack of funding and services for young people; and
  • a shortage of mental health professionals.

6.4.9.1 Current state of mental health services

The Rann government's inaction on community mental health services can only be described as contempt for South Australians affected by mental illness.

(SANE Australia, National, Submission #302)

Doctors and mental health people will not give us what is necessary to help my son. There are often throw away comments such as "the mental health system is not working", "there's not enough money", "there's little that can be done", "he has to seek the help".

(Carer, Mother, South Australia, Submission #11)

If you spend more dollars on an inefficient and traumatising system, without reforming and modernising first, it will not only be a waste of time, energy and dollars, but will result in a larger mess than before.

(Consumer, South Australia, Submission #335)

On a personal note, there seems to be this amazing reform occurring in SA (so they say anyway). A great deal of money has been allocated but it seems to be for Capital Works. The future for SA seems to be that we will have lovely new buildings / wings etc but of great concern will be the lack of well educated and supported workforce dealing with clients with very specific needs. The lack of supports etc when the client goes home?? We will see terrific buildings but I am very concerned that the foundations are faulty. The foundations of mental health do not only belong within the hospitals / clinics they need to stretch out further into the communities - reinforcement needs to extend itself. We have seen the problems that have occurred in Western Australia and are aware that it could so easily occur here.

(Anonymous, South Australia, Submission #61)

[N]ot much has changed in the country Post Burdekin ... A few years ago (but since Burdekin) my brother in law hung himself - in his shed in a country town. This followed at least 2 prior attempts. Although he presented to the local GP at no time was he detained or in receipt of anything close to resembling reasonable psychiatric care. His poor mental health was long standing ... Everyone in town also knew about his alcohol addiction ... the treating GP had treated many of [his family] for many years ... so he knew who & what he was dealing with ... I believe that he left a note which was quite readable and was able to make the necessary arrangements to hang himself in a space some distance from his home. On his 2 previous attempts (and there could well have been more) he was unsuccessful because the methods offended his sense of not wanting to make a mess - and he didn't get any appropriate help. Given that that GP is still the dominant medical officer in town & not much else has changed in terms of service availability, I don't think my brother in law's prognosis would be any different today. Now I fear for his son's life.

(Family Member and Service Provider, South Australia, Submission #34)

6.4.9.2 Lack of resources and services and the impact of this on clinicians

We have some excellent workers but they aren't resourced to be able to provide the sort of care people need.

(Anonymous, South Australia, Adelaide Forum #9)

Many presentations were made at forums indicating the negative impact on staff of lack of resources and lack of other services to assist with the delivery of quality treatment and support to consumers and their carers. Feelings of burnout, 'craziness' and stress were reported and observed by clinicians and consumers.

I am a clinical psychologist and I left the mental health system because of burnout and the feeling that in my previous role I felt like I was perpetuating the abuse because I didn't have the resources I needed to do my job properly.

(Anonymous, South Australia, Adelaide Forum #12)

I work as a clinical psychologist in the mental health service. Some days I feel crazy each day.

(Clinician, South Australia, Adelaide Forum #11)

Staff conditions ... day-to-day conditions are so poor we struggle to work.

(Clinician, South Australia, Adelaide Forum #11)

Staff turnover in the mental health services is very high. We're lucky if we get an allied health worker to stay for 3 months.

(NGO Worker, South Australia, Adelaide Forum #24)

6.4.9.3 Distribution of services - lack of services in rural and regional areas

...there has been ongoing debate regarding the mal-distribution of medical services in Australia ... The majority of medical services have been concentrated in capital cities and major regional centres and have been quite limited in rural and remote areas. It has become increasingly difficult to recruit and retain general practitioners (GPs) in country areas and there is a long history of difficulties in the provision of specialist services outside large population centres. It is a fact that there are relatively few medical specialists living and working outside major regional centres ... For example, in South Australia in 1997, only 1.1% of psychiatrists lived outside Adelaide.

(Clinician, South Australia, Submission #274)

One of the key concerns expressed both directly and by implication, and particularly at the Murray Bridge Forum, was of the lack of services in rural and remote areas of South Australia. Many consumers and carers spoke of the absence of any service to access and their only options were at a great distance away. Due to the scarce number of services, these services are difficult to access (e.g. long waitlists) and involved great disruption on a daily or long-term basis. Additionally, if long term treatment or supported accommodation is required, this involves removal of consumers, and sometimes carers, from social support networks and employment, and often at considerable financial cost.

Historically, specialist services to rural and remote areas have generally been provided on a visiting private practice basis, sometimes with State Government or local area funding support. In more recent years with the development of tele-conferencing facilities, it has become possible to provide a number of services at a distance from a capital city base. Psychiatric services are a good example of this and tele-psychiatry consultations have been performed by the Rural and Remote Mental Health Service of South Australia since 1994.

(Clinician, South Australia, Submission #274)

The hospital facilities for regional South Australians needing inpatient treatment are in the city (Glenside Hospital) which means that hospital patients with a mental illness who come from country areas such as the Murray Mallee are removed from their families and networks. Secure hospital facilities in regional areas are needed.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

As mentioned previously, the Medical Specialist Outreach Assistance Programme has improved access in rural and remotes areas.

The new MSOAP services are likely to improve continuity of care and will help prevent future complications and trauma, both for the patient concerned and the local community. Indigenous South Australians are also beginning to benefit from MSOAP initiatives.

(Clinician, South Australia, Submission #274)

What has improved in the South Australian Murray Mallee region:

•  There are more mental health workers in the region than there were 10 years ago, which has given some people with mental illness better access to supports.

•  The Mental Health Line / Rural and Remote Triage has helped to reduce the isolation for those in the region who suffer from mental illness and for those who support them.

•  Telemedicine and videoconferencing facilities have enabled more people to have access to psychiatrists.

•  Recent group programs such as the women's strength-building course have assisted women in the region to enjoy improved mental health and self confidence.

(Health and Community Services Network, Murray Mallee Strategic Task Force, South Australia , Submission #115)

Despite these improvements, however, the evidence presented suggests that the model of service and resource distribution across South Australia needs to fundamentally change in order to ensure that the rights of consumers and their families are protected. This included access (according to Standard 11.1; equitable access) to treatment and support services for all stages of the recovery process (according to Standard 11.4) as well as access to supported accommodation (Standard 11.4.B) and services to support the consumer's quality of living (Standard 11.4.A).

We don't have enough workers here - our workers are always stressed. We can't expect much off them. One of the things we will do will be to lobby government.
(Consumer & Advocate, South Australia, Murray Bridge Forum #8)

As recommended by the Health and Community Services Network, Murray Mallee Strategic Task Force, access to both community based services and acute care treatment facilities (for example, closer proximity) need to improve.

Recommendation: That funding is allocated to community support services in rural areas (and not just for those living in regional centres) to supplement clinical mental health services. These services should include programs aimed at reducing social isolation, developing confidence and self esteem and promoting integration into the wider community. These programs should also include support for people with a mental health disability to return to study or work.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

Recommendation: That secure facilities for mental health patients are provided in regional hospitals with staff trained in psychiatric nursing and associated allied health professions.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

Two submissions also highlighted staffing issues. The first argues that any plan to increase services in remote and rural areas needs to address staff recruitment and retention issues which have hindered the filling of vacancies in the past.

There are a number of reasons why it has been so difficult to attract specialists to work and live in country areas ... These include the isolation from peer support, the demands of families, including the career needs of the spouse and the educational and other needs of children, as well as likely future difficulties in returning to metropolitan practice. There can also be problems in limiting service demands and the potential for associated 'burnout'. Furthermore, there are the unique stresses associated with living in a small community where there is a lack of anonymity and the likelihood of more intense public scrutiny of one's day-to-day activities. There may be financial disincentives associated with working in country areas. There can be major difficulties for the clinician in providing for his or her emotional and professional needs. For example, it can be hard to establish and maintain support networks locally, particularly for clinicians working in such an emotionally intense area as psychiatry. It is also hard to provide for one's recreational needs, including holidays, because there may be a limited availability of local support and after-hours back up, and the likelihood of having to deal with clinical emergencies after hours would be particularly draining. Finally, there are often major constraints upon the opportunities to engage in regular professional development and ongoing educational activities, such as attending conferences and medical college seminars.

(Clinician, South Australia, Submission #274)

There is [sic] not enough nurses, social workers and psychiatrists in the country where as in the city there are more however even in the city staffing in the mental illness field is less than satisfactory.

(Consumer, South Australia, Submission #77)

6.4.9.4 Model of mental health care needs to change - lack of community-based services and inappropriate focus on inpatient and crisis care

Concerns were expressed about the model of mental health care underlying service delivery and planning in South Australia. Concerns were raised about the emphasis on inpatient and crisis care and the medical model. Concern was also raised regarding 're-institutionalisation' as people with mental illness are now being diverted and 'institutionalised' in prisons. This emphasis needs to change to improve outcomes for people with mental illness.

There have been three mental health plans since the Burdekin Report. There have been great advances in medication - there have been great collaborations with GPs and other reforms with strong evidence bases and new technologies developed. But we remain one of the lowest spending countries in terms of what we spend on mental health care. We spend almost half what other countries spend. We spend very little on supported accommodation where it's really needed and we still spend a lot on inpatient or crisis care. The problem is that we are locked into an old model. The evidence suggests that people do need supported accommodation - but the system has been poorly funded in SA.
(NGO Worker, South Australia, Adelaide Forum #22)

This institutional model extends into the prison system. The Chair of the SA Parole Board has drawn attention to the high number of people with a mental illness in the State's prisons, saying the government was using them as a 'sump' for people who should be cared for by mental health services.

(SANE Australia, National, Submission #302)

I am extremely concerned about the use of restraint and seclusion in SA hospitals. There have been frequent recent stories of psychiatric patients being shackled in the ED [Emergency Department] at central city hospitals, inappropriate use of seclusion (for staff convenience not patient care), the use of outmoded and banned restraint holds by nurses and patients not being treated with the care and respect they deserve.

(Academic, South Australia, Submission #142)

We've got a 19th century hospital system with 21st century demands.

(Anonymous, South Australia, Adelaide Forum #9)

We have medicalised something which is not necessarily medical - there are potentially harmful side-effects. For a start it takes away ownership of the problem/the illness.

(Academic, South Australia, Submission #219)

[Recommendation] Decisive action by the State government to reform South Australia's mental health services in consultation with the Mental Health Coalition of SA - committing political will and resources to close Glenside and implement community-based services, with acute wards mainstreamed into general hospitals and a new forensic facility.

(SANE Australia, National, Submission #302)

We need more emphasis on people's social & spiritual needs.

(Social Worker, South Australia, Adelaide Forum #20)

The mental health system here in South Australia is too weird for me.

(Carer, Family Member, South Australia, Adelaide Forum #2)

6.4.9.5 Lack of consultation with consumers, carers and staff

Concerns were expressed about the lack of consultation with clinicians, consumers and carers in the planning and delivery of mental health services. According to Standard 9.8, a strategic plan is to be 'developed and reviewed through a process of consultation with staff, consumers, carers, other appropriate service providers and the defined community'. Clinicians and consumer advocates spoke of the need for genuine consultation, 'to be heard' about their needs and to contribute innovative ideas to solve service delivery problems.

...there is a tokenistic response to staff who have innovative ideas - great program.

(Clinician, South Australia, Adelaide Forum #11)

There is a token approach to consumer and carer participation - tokenistic responses. There is no carer and consumer input. No feedback.

(Clinician, South Australia, Adelaide Forum #11)

There's a need for a rural consultation in areas like Port Augusta. There are huge workloads for staff and GPs in our area ... There's also a need for consumers, carers etc to be heard and to be supported with funding.

(Advocate, South Australia, Adelaide Forum #15)

The following statements from a clinician provide just one example of the tokenistic responses experienced by those staff who seek improvement of the mental health services, and of the repercussions that may be experienced for attempting to do so.

It is evident to clinical staff that contributions to policy formulation or micro-reform suggestions aimed at service improvement are not welcome. In the rare instances where consultation processes exist they are tokenistic, without power and their outcomes are not acted on. When suggestions / proposals are submitted they are ignored as a rule. If the person making suggestions, raising issues insists, s/he will be increasingly ignored, and should s/he persist, s/he will be marginalised, described as having a 'bee in his / her bonnet' or 'a chip on his / her shoulder'. This may gradually degenerate in outright denigration of his / her work or person on the part of managers, team leaders, including character assassination which outside of the Public Service would be subject to slander and libel laws.

(Clinician, South Australia, Submission #56)

Day to day working conditions within the mental health services are often so poor that staff are struggling to contend with the daily issues of accommodation, equipment, safety provisions and aspects of managerial culture. Consequently, staff are less able to address the more complex issues of service reform. A culture of inertia and hopelessness sets in, as staff are forced into a position of simply having to cope with less than adequate working conditions.

(Clinician, South Australia, Submission #56)

As with the tokenistic responses to consumer and carer participation, staff initiatives for service improvement frequently remain unsupported, if not discouraged ... Staff advocacy for the development of a hospital at home program was similarly discouraged and a proposal to aid the development of culturally appropriate service has been unsupported. Whilst it is apparent that not all proposals can, or should, be supported, the more fundamental issue that is being raised here is of a culture that does not foster the development and implementation of new ideas, but which actually might be seen to discourage them. Further, questions must be raised as to the commitment to the National Mental Health Strategy.

(Clinician, South Australia, Submission #56)

6.4.9.6 Lack of mechanisms to improve service delivery and accountability

Associated with concerns about an inability to contribute in a positive manner to service improvement are concerns about speaking up and fear of consequent reprisal. Accountability ensures the protection of rights of people with mental illness and practices to ensure delivery of quality care. Standard 9.2 states: 'There is single point accountability for the MHS across all settings, programs and age groups', and Standard 9.29 states 'The MHS has an evaluation strategy which promotes participation by staff, consumers ...'.

I have advocated in the past on behalf of a mental health worker who wanted some changes to occur - because they are employed by the system they get into trouble if they speak up, they can't speak up.

(NGO Worker, South Australia, Adelaide Forum #24)

Sheer bullying and harassment of staff who speak out is a problem - we need to strengthen the culture. The Equal Opportunity Act in South Australia still doesn't include mental health - we know it will be on the table in September and we would appreciate your support.

(Clinician, South Australia, Adelaide Forum #11)

6.4.9.7 Lack of funding

Along with reports about the need for increased funding and services for many vulnerable groups described elsewhere in this Report (for example for children and youth with mental health and drug and alcohol problems) one consumer advocate expressed particular concern about the lack of funding for people with co-occurring physical disability and mental illness or mental health problems. The health care needs (both physical and mental) for people with physical disability beyond those directly associated with their specific physical disability are a common problem faced by this group. SANE Australia's SANE Mental Health Report 2004 also discusses funding concerns.

I am here representing people with physical disabilities who also have a mental health problem ... The funding is extremely important, we need adequate funding for appropriate services.

(Consumer and Advocate, Female, South Australia, Adelaide Forum #3)

While other jurisdictions spend around 47% of the mental health budget on hospitals, South Australia spends a massive 60% - in fact, around 45% of the entire mental health budget continues to be swallowed up by Glenside Hospital.

(SANE Australia, National, Submission #302)

As well as limited funding for community-based clinical services, the proportion of the mental health budget allocated to non-government organisations providing community support has shrunk to a minuscule 1.9%. The key area of supported accommodation receives just 0.4% of the mental health budget (compared to 17.9% in better funded States).

(SANE Australia, National, Submission #302)

Some additional funding has been released for mental health services since 2002, primarily for clinical services and often on an ad hoc basis. This includes a welcome $11.4 million for supported residential facilities and extra support for case management. A further $800,000 has been spent to increase security at the Glenside Psychiatric Hospital - mainly, it would seem, in response to local media 'beat-ups' about patients leaving the grounds (whom they misleadingly describe as 'inmates' who 'escape' and have to be 'recaptured').

(SANE Australia, National, Submission #302)

6.4.9.8 Affordability of care: public versus private

In contrast to the many concerns raised by consumers, carers, clinicians and academics about the quality of public mental health service delivery in South Australia, the following report from a carer at the Adelaide forum is potentially an indicator of a growing trend in health care: that only those with the financial resources can access 'marvellous' mental health care.

The Adelaide clinic (private clinic) has been marvellous with our family and the new young shrink has been marvellous.

(Carer, Family Member, South Australia, Adelaide Forum #2)

Also of serious concern, was the following remark made by a consumer who was unable to find a bulk billing psychiatrist and making it difficult to access care if she was struggling to pay the gap required.

But then the problem in Adelaide if you can get up there is that there's very little bulk billing by psychiatrists in Adelaide. Earlier in the year I was told that I needed a psychiatrist but I couldn't find one that was bulk billing that was taking new patients.

(Consumer, South Australia, Murray Bridge Forum #2)

6.4.9.9 Problems with funding arrangements for service providers

Concern was expressed regarding funding arrangements for services, the brevity of the contracts, the competitive tendering process and the negative impact these processes have had on collaborative arrangements between agencies:

I am currently trying to set up [Y] for residents of Supported Residential Facilities in Adelaide under a new funding arrangement. While this all sounds wonderful, I have serious reservations some of which tend to be funding based:

•  our funding is only for 12 months at a time and there is pressure on us from 'bureaucrats' to provide them with data to prove we're achieving outcomes which are still vague but in the realm of a long term research project & have no relationship to the level of chronic ill-health - mental & physical) & the level of dysfunctionality due to long term institutionalisation. Initially I was led to believe that the funding would be for 4-5 years (1 year of service delivery has been lost while bureaucrats thought about what to do) but it seems we'll only be funded year-by-year for up to 4-5 years. This has implications for planning effective services, recruiting staff etc.

•  some of the new services are to be provided by NGOs. Prior to the tendering process for provision of these services, there was significant & positive collaboration between all of the NGOs & govt agencies - this level of collaboration has now diminished to include those agencies receiving specific funding - we've lost a pool of partners because of a competitive tendering process.

(Family Member and Service Provider, South Australia , Submission #34)

6.4.9.10 Lack of funding and services to meet the needs of young people

The Youth Affairs Council of South Australia expressed concern that the level of funding allocated to youth services and programs was inadequate to meet the mental health needs of young people and called for equitable distribution of mental health funding;

The greatest burden of disease for young people is mental health. In 2000-2001, up to 20% of young people aged 12 to 17 and more than one quarter of 18 to 24 year olds experienced mental health issues, making mental health a strong priority for YACSA in this submission. Funding allocated does not reflect the significant impact mental health issues have on young people, and YACSA contends that a more equitable distribution of mental health funding to young people should be determined ...

(Youth Affairs Council of South Australia, South Australia, Submission #38)

 

Because of concerns that homeless young people with high and complex needs including mental health issues are not being well served by accommodation, support and health services, YACSA has conducted consultations with providers and consumers. The key findings of those consultations are also supported by various recent reviews and research into this area ... In summary the findings are that services are characterised by:

•  High and increasing demand associated with the combination of mental health problems and homelessness leading to higher rates of hospitalisation, arrest, misuse of alcohol and drugs etc

•  Increasing numbers of young people presenting to agencies with an increasingly severe range of problems in relation to:

•  Sexuality related issues
•  Behavioural problems
•  Substance abuse
•  Depression / anxiety
•  Violence/anger
•  Grief / loss
•  Homelessness
•  Physical and / or sexual abuse

•  Fragmentation of services, especially given that clients usually present with multiple needs that may require the involvement of multiple agencies across several sectors

•  A tendency for 'difficult' clients to be 'handballed' to other services - that is, referred without any communication between agencies

•  A particular shortfall in supported residential services with access to mental health outreach and support

•  A concentration on highly focused, short term, acute crisis management casework at the cost of continuity of care and a community development capacity

•  A pressure to meet the funding body numbers - output not outcomes

•  Restrictive eligibility criteria (age, geographic, diagnostic and behavioural) especially for high need / severe cases, leading to exclusion and consequent exacerbation of mental health issues, homelessness, and associated problems

•  Poor communication across sectors, characterised by confusion about respective roles and expectations

•  A lack of flexibility of response from many agencies, failing to address the widely varied immediate needs of young people, and therefore failing to engage with them

(Youth Affairs Council of South Australia , South Australia , Submission #38)

One major consequence of this situation is that a relatively small number of young people with high and complex needs, whose extreme and repeated behaviours have effectively excluded them from SAAP [Supported Accommodation and Assistance Program] accommodation and other supports, are relying on hospital admissions for accommodation and support and creating a significant demand on police and the criminal justice system. The costs to government incurred by this small group are substantial. This proposal argues that a comparatively small investment in a new capacity -building service could significantly reduce these costs.

(Youth Affairs Council of South Australia, South Australia, Submission #38)

6.4.9.11 Shortage of mental health professionals

Associated with the lack of services are reports of an excessive demand for the services that exist, and reports that these services often had difficulties recruiting and retaining staff. The shortage of qualified mental health professionals was noted as a critical problem:

Firstly, one of the areas we have had difficulty in is finding workers that have training or experience in working with people with mental illnesses. Much training is based around aged care or general disability. We would like to provide more support to carers of people with mental health conditions but we need to ensure that we have appropriate, qualified workers available to assist with the respite care. Secondly, one of our constraints is that we cannot provide respite care if it is an "at risk" situation for the worker. If a person is having an acute episode, we may not be able to provide respite care to allow the carer to have a break- hospital admission may be the only option.

(Service Provider, South Australia, Submission #57)

6.4.10 STANDARD 10: DOCUMENTATION

Clinical activities and service development activities are documented to assist in the delivery of care and in the management of services.

Under this Standard, submissions and presentations indicate concerns about:

  • documentation systems not being utilised; and
  • carer's plea for access to be corroborated with clinical records ignored.

6.4.10.1 Documentation systems not being utilised

Standard 10.2 states 'Treatment and support provided by the MHS are recorded in an individual clinical record which is accessible throughout the components of the MHS' and Standard 10.4 states 'A system exists by which the MHS uses the individual record to promote continuity of care across settings, programs and time'. According to one NGO worker this is not occurring and consumers are becoming frustrated at having to tell their stories repeatedly. Additionally, if records are not being accessed, this would also imply that clinicians are also not entering data regarding any interventions (Standard 10.5, 'Documentation is a comprehensive, factual and sequential record of the consumers' condition and treatment and the treatment and support offered') and signed and dated (Standard 10.3).

The system is stuffed and so difficult for consumers to navigate. People have to tell the stories over and over again to a range of different people. They should only have to tell their story once.

(NGO Worker, South Australia, Adelaide Forum #24)

6.4.10.2 Carer's plea for access to be corroborated with clinical records ignored

In one submission a mother highlighted a problem with accessing care for her son and hoped that his record could be used to corroborate his need for treatment as he was too ill to request the help himself.

I rang ACIS (Assessment and Crisis Intervention Service) on the afternoon of 27/2 [2004] in an attempt to understand how things had gone so wrong. [Y] told me that there had been several phone calls made to [X] by ACIS and that he had not wanted intervention!!! We are referring here to a man who ... HE HAS NOT BEEN WITHOUT SOME FORM OF TREATMENT OR DETENTION ORDER SINCE ABOUT 1988 AND HE WAS CONTINUALLY UNDER... DETENTION AND OR COMMUNITY ORDERS IN THE PRECEEDING FIFTEEN MONTHS. There is an ample collection of SA files on [X] ... (author's emphasis)

(Carer, Mother, South Australia, Submission #279)

6.4.11 STANDARD 11: DELIVERY OF CARE

Principles guiding the delivery of care: The care treatment and support delivered by the mental health service is guided by: choice; social, cultural and developmental context; continuous and coordinated care; comprehensive care; individual care; least restriction.

Under this Standard outlining the principles underlying care, submissions and presentations indicate concerns about:

  • the lack of choice and individualised and continuous care currently available in mental health services.

Further evidence supporting this is presented under other subsections of this Standard.

6.4.11.1 No choice, no continuous care, no individual care

The family is facing another situation of the ultimatum between participating in the complete program with suspension of their preferred treating professionals, or repeating the above process with no guarantee that there will be another premature discharge that places the young person's life at risk, let alone another experience of not being heard, and no willingness for collaboration that works toward shared approaches and negotiated goals wherever possible.

(NGO Service Provider, South Australia, Submission #233)

This example presented by an NGO service provider raises serious concerns that nearly all the underlying principles governing the delivery of care are not being implemented resulting in the young person's life being placed at risk. Other similar concerns were expressed at the forum held in Adelaide:

People need choice - the current system doesn't afford choice - it's falling over.

(Social Worker, South Australia, Adelaide Forum #20)

I'm really disgusted with the situation, I went to a mental illness conference in Canberra last year and heard someone say that people are treated like 'objects' - I believe that because that's what it's like in Adelaide.

(Carer, Consumer & Advocate, South Australia, Adelaide Forum #5)

In the country you don't have a choice of psychiatrist, and there is no alternatives [sic] when it comes to what is available to help you. There is no therapy, little in the way of counseling [sic] and no choice but to do your own rehabilitation.

(Consumer, South Australia, Submission #77)

An extreme example of the consequence of the inability of one mother to obtain the care, treatment and support she required for her son was that she decided she could no longer care for him and made him a ward of the State.

[X] became a ward of the state because I was aware I needed help with his personality changes and respect for himself.

(Carer, Mother, South Australia, Submission #195)

6.4.11.1 Access

The MHS is accessible to the defined community.

Under this Standard, submissions and presentations indicate concerns about:

  • attitudes towards Indigenous people;
  • operational policies which limit access (opening hours and mode of contact);
  • a crisis is required before services can be accessed;
  • carers concerns are being ignored;
  • long waitlists or no clinicians available at all;
  • lack of services for people with mental illness and complex needs; and
  • lack of services for people with personality disorders.

An inability for consumers to access treatment and support services, both within the community and inpatient care, often results in a whole series of rights being infringed for consumers, carers and the community. For the consumer, the consequences of these infringements can include consequences ranging from increasing disability, and hence consequent inability to care for oneself or others, participate socially or work or study, to (in some cases) the potential for harm to self or others, and to becoming poor and ultimately homeless. Increasing disability can also further expose the consumer and their family to discrimination and social exclusion, further compounding their illness.

For children and youth, failure to gain access to services at this time of their life can place their future life course at risk. For example, if they are expelled from school, their problem behaviours can increase, further disrupting their relationships with their peers.

Similarly, increased burdens on carers can disrupt their ability to participate socially and work when their family member became increasingly ill and require increasing care. Family isolation and increasing instability were also frequently reported due to the lack of community support and acceptance (high levels of stigma and discrimination) and lack of family-centred approaches to treatment and support. For the community, rights to safety can be infringed upon and social and economic cohesion disrupted.

6.4.11.1.1 Difficulties being experienced by Indigenous people

The main problem for Indigenous people is that people are so judgemental of Indigenous people. Our clients are most often judged as taking drugs or alcohol and not being mentally ill. Because of this, because it's easy to say they've taken something, they receive no mental health care. It's very hard when we go to government services for care.

(Clinician, South Australia, Adelaide Forum #13)

According to Standard 11.1.1 'The MHS ensures equality in the delivery of treatment and support regardless of consumer's age, gender, culture, sexual orientation, socioeconomic status, religious beliefs, previous psychiatric diagnosis, past forensic status and physical or other disability'. Despite this, concerns were expressed regarding the inability of Indigenous people to access care due to discriminatory attitudes and beliefs. As a result, care has been denied to Indigenous people. As an example of the barriers experienced by Indigenous people, a clinician at the Adelaide forum described the lengths one Indigenous person went to access care:

...Indigenous people ... I want to tell you about a guy that I saw on the streets. He went to the Royal Adelaide Hospital to seek treatment and they basically told him to piss off. I picked him up off the streets with 2 broken legs and a broken hip. He jumped off the bridge so he could get help.

(Clinician, South Australia, Adelaide Forum #13)

By contrast, at the Murray Bridge Forum, a more positive picture was described with regards to services for Indigenous people as a result of the involvement of Indigenous workers. Unfortunately, services appear limited due to lack of resources.

We have a high population of indigenous people. The indigenous workers are great but they are so stretched. We have data from York Peninsula from programs they have run there that shows that if people with a mental illness are supported to break down their social isolation then they do get better and it aids with their rehabilitation.

(Community Health Service worker, South Australia, Murray Bridge Forum #9)
6.4.11.1.2 Operational policies are limiting access (opening hours and mode of contact)

Standard 11.1.4 states: 'The MHS is available on a 24 hour basis, 7 days per week' and Standard 11.1.3 further states ' ...in a convenient and local manner'. One police officer expressed concern that as a result of services only being available during office hours, the police service was the de facto after-hours service. This is of grave concern on many levels, not the least of which is the stigma for the consumer and their carers resulting from contact with the police which is misinterpreted as threats to safety or criminality.

I see a real lack of home support for people living with a mental illness. After hours there's no after hours support - that is when they call on us.

(Police Officer, South Australia, Murray Bridge Forum #16)

Another 'equality of access' concern was raised by an NGO worker for people with mental illness who are poor. In many areas, mental health service providers have tried to ensure 24-hour access by the provision of a phone service. However, focus on a single mode of contact disadvantages consumers who do not have a phone or who can only receive calls. Standard 11.1.3

I work for a consumer / carer organisation. We rely on volunteers and we've been operating since 2001. I want to raise an issue about providing phone support. It is important to be able to provide phone support but we also need to recognise that many of our clients cannot phone out - they can only accept incoming calls because they can't pay their phone bills.

(NGO Worker, South Australia, Adelaide Forum #24)
6.4.11.1.3 Crisis required before access is permitted

As illustrated in the example above with the Indigenous person who jumped off a bridge to access care, another report was received providing further evidence that often care cannot be accessed until a person is either a threat to themselves or others. This further supports other evidence that prevention and early intervention are not a key focus of service delivery in South Australia.

Someone close to me has 'episodes' and nobody wants to know until he's done something wrong and then the police are called.

(Carer, Consumer & Advocate, South Australia, Adelaide Forum #5)

One police officer reported the tragic story of a woman who the police had tried to assist to care, but failed. The women died as a result.

I can tell you about a woman who arrived on a bus from Victoria - we tried to certify her three times one weekend. We couldn't get her certified but then she jumped off the bridge.

(Police Officer, South Australia, Murray Bridge Forum #16)
6.4.11.1.4 Carers not heard

Another example supporting claims that a crisis is required before services are provided is that carers are unable to initiate a response from services. One mother outlined her desperate attempts to access services for her son who was becoming increasing unwell (and who was well known to the mental health service) but her notification and attempts were ignored.

I rang ACIS on the afternoon of 27/2 [2004] in an attempt to understand how things had gone so wrong. [Y] told me that there had been several phone calls made to [X] by ACIS and that he had not wanted intervention!!!

(Carer, Mother, South Australia, Submission #279)
6.4.11.1.5 Long wait lists or no clinicians available

Apart from contact with professional mental health workers there are no ongoing community support programs in the Mallee outside the regional centre of Murray Bridge.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

Reports were also received regarding the lack of sufficient staff and services to meet the needs of the community, especially in rural and remote areas. This was evidenced by long wait lists for the staff available, or no staff or services to meet the needs of special groups. Standard 11.1.2 states: 'The community to be serviced is defined, its needs regularly identified and services are planned and delivered to meet those needs'.

I work 7 days a week at the hospital in accident and emergency. This is a shared position with [MH nurse]. Together we cover the 7 days. I have requested for someone to see Dr [Z], the visiting psychiatrist. It can take weeks or even months wait before someone can get in to see a psychiatrist.

(Clinician, South Australia, Murray Bridge Forum #5)

There's only a visiting psychiatrist for this area. They come 1 day a week. We need more access than that. But then the problem in Adelaide if you can get up there is that there's very little bulk billing psychiatrists in Adelaide. Earlier in the year I was told that I needed a psychiatrist but I couldn't find one that was bulk billing that was taking new patients. There's not even a social worker here now, no OT now, no psychologists after several years. It's all left to the mental health nurses who are expected to carry the load.

(Consumer, South Australia, Murray Bridge Forum #2)

In the country there is no resident psychiatrist and I had to travel to Adelaide on a regular monthly basis to see a psychiatrist. This meant petrol money, and travel of an hour duration each way. Other specialists I have seen also consult in Adelaide for the most part. The cost of travel to Adelaide together with an hour drive there and back and an appointment of only ten minutes or so became unsatisfactory and unaffordable. Now we have a visiting psychiatrist once a fortnight but this can't reasonably enable all mentally unwell people to see her. I am none the less thankful she comes to Murray Bridge.

(Consumer, South Australia, Submission #77)

Services such as visiting psychiatrists often offer no choice and long times between visits. If I travel to Adelaide to see a psychiatrist there is an hour trip down and back for a ten minute consultation. The petrol cost and short interview led me to stop seeing a psychiatrist and instead see a GP regularly.

(Consumer, South Australia, Submission #77)
6.4.11.1.6 Lack of services for people with mental illness and complex needs

Given the reports above regarding difficulties in accessing services, it was not surprising to hear that consumers with complex needs found even further barriers. Police describe circumstances of being left to deal with 'the difficult clients no one wants' and concerns were expressed about services for people with eating disorders, behaviour problems and drug and alcohol problems.

People are being given bus tickets to be moved on ... we're left dealing with the difficult clients that no one else wants.

(Police Officer, South Australia, Murray Bridge Forum #16)

At the beginning of this year, I began to suffer debilitating depression and eating disorder symptoms. I sought help in the Emergency Department of Flinders Medical Centre three times. The first time I sought help there, I waited well over 3 hours to be seen, then was admitted and left in "Extended Emergency Care Unit" for 3 days, then discharged because there were no beds available in the Psychiatric Ward. The second time I presented, I gave up after a day in the EECU. I was on the waiting list for a bed, and after a number of weeks and another presentation to FMC Emergency, I finally got admitted.

(Consumer, South Australia, Submission #158)

He tried cutting down on his antidepressant tablets when he was living in Salisbury about five years ago. He was bed ridden and physically ill in his attempt. He was crying out for help. He rang Glenside a few times and tried to convey to them by phone his desperate situation. His frustration in being dismissed combined with his lack of verbal and social skills resulted in the opposite from obtaining help. Again [X] faced court and was charged with abusive language. The system that should have protected [X], failed him.

(Carer, Mother, South Australia, Submission #195)

There is a drug and alcohol service in the area but it doesn't work with the mental health service. People get pushed between the services. People with both problems get told to go to the other service for help.

(Consumer & Advocate, South Australia, Murray Bridge Forum #8)
6.4.11.1.7 Lack of services for people with personality disorders

Many reports were received regarding the lack of treatment and support options for people with personality disorders (discussed in section 11.4 Treatment and Support). As a consequence, access issues were for this group were seen as critical.

I'm concerned for those people who are seriously mentally ill. They are reluctant to go to mental health services because they are told there is no or minimal help for people who have been labelled as having personality disorders.

(Consumer, South Australia, Adelaide Forum #16)

6.4.11.2 Entry

The process of entry to the MHS meets the needs of the defined community and facilitates timely and ongoing assessment.

No submissions or comments were received pertaining to this Standard.

6.4.11.3 Assessment and review

Consumers and their carers receive a comprehensive, timely and accurate assessment and a regular review of progress.

Under this Standard, submissions and presentations indicate concerns about:

  • the quality of the assessment and review process; and
  • assessment concerns for people from a non-English speaking background.

6.4.11.3.1 Concerns about the quality of the assessment and review process

One carer described the apparent failure of services to conduct an adequate assessment and provide treatment to a consumer who openly declared he was suicidal.

He went to The Flinders Medical Centre three times and told them he was suicidal and asked for help. He badly needed to be admitted for assessment in Glenside. They kept him overnight a few times and then let him go.

(Carer, Mother, South Australia Submission #195)

And yet another carer said that she did not believe the 'principles of good practice' had been applied in her son's case:

[X] needed a comprehensive assessment of his condition and medication but I believed that he would either find his own way to hospital through his bizarre / anti-social behaviour or would be assessed by ACIS as requiring admission ... I have re-read the glossy booklet P8-02 Assessment and Intervention Service and I cannot see how the 9 Principles of good practice have been applied in this case. And in particular, nowhere do I find that it is only the willing consumers who get a service while the remainder become the responsibility of the Police.

(Carer, Mother, South Australia, Submission #279)

Standard 11.3.3 states "The MHS has a procedure for appropriately following up people who decline to participate in assessment'. Clearly this carer felt that this Standard was not met and that the mental health service had handed over their duty of care for these people to the police.

6.4.11.3.2 Assessment concerns for people from a non-English speaking background

Even though Standard 11.3.9 states: 'There is opportunity for the assessment to be conducted in the preferred language of the consumer and their carers' and Standard 11.3.10 states 'Staff are aware of, and sensitive to, language and cultural issues which may affect the assessment', there were some who did not perceive this be the case. For example, concern was expressed about the potential misdiagnosis of a person from a non-English speaking background, which could indicate problems with the assessment process:

A consumer reported that he had been tortured in a military context, in which it is conceivable that such an event might have taken place. The initial interpretation by mental health staff was that he was psychotic. No other possible explanations were entertained. A second interpretation by staff, some weeks later was that the man reported things that were so incredible that he was not to be believed. This was accompanied by the observation that the man in question presented with signs of physical injury. It was at this time that staff refused to refer to Survivors of Torture and Trauma, or to a Clinical Psychologist of the man's own cultural background, for a more comprehensive assessment. The man concerned was of an NESB background and did not possess English in his linguistic repertoire. Hence, the need for informed assessment was doubly important. Some weeks later, staff made the observation that it turned out that the man was right and that he had been tortured. This conclusion was not reached by a methodical process of assessment and, as such, appears to have occurred through good fortune rather than through good management. It was not accompanied by any reflection on the earlier conclusions that had been reached.

(Clinician, South Australia, Submission #56)

6.4.11.4 Treatment and support

The defined community has access to a range of high quality mental health treatment and support services.

I guess I am writing this letter in desperation for help as I continually worry about my son ending up just another suicide victim.

(Carer, Mother, South Australia, Submission #195)

Under this Standard, submissions and presentations indicate concerns about:

  • restrictive and intrusive practices;
  • lack of involvement of carers;
  • lack of services for refugees and newly arrived immigrants;
  • lack of services for people with dual diagnosis (drug and alcohol);
  • lack of services for people with physical disability;
  • lack of services for the aged;
  • lack of services for people with personality disorders; and
  • lack of services for people with eating disorders.
6.4.11.4.1 Restrictive and intrusive practices

While acknowledging the difficulty of service provision to consumers with complex problems and behaviours, it is expected that specialist mental health services will have and use the necessary skills to engage people with such a profile, who are recognised as a priority consumer group. It is proposed that successful engagement with the consumer can improve the chances of good outcomes without resorting to the most restrictive forms of care. (excerpt from a letter from the Director of Mental Health, Mental Health Services and Programs, Department of Human Services, 2004)

(Carer, Mother, South Australia, Submission #195)

Standard 11.4.10 states: 'The MHS provides the least intrusive treatment and support possible in the environment and manner most helpful to, and most respectful to, the consumer.' However, reports were received indicating that this is not the case. One academic alleged that restraint practices were being used across South Australia and another NGO reported coercive approaches to treatment.

Restraint practices across the state appear to be often cruel harsh and in many cases, in breach of the WHO [World Health Organisation] guidelines re least restrictive environment.

(Academic, South Australia, Submission #142)

Some of our clients report having been threatened by a mental health worker that they will be admitted if they get upset during a session. This is control through fear, it's not good mental health care.

(NGO Worker, South Australia, Adelaide Forum #24)
6.4.11.4.2 Lack of involvement of carers

Despite Standard 11.4.9 acknowledging the involvement of carers ('There is a current individual care plan for each consumer, which is constructed and regularly reviewed with the consumer and, with the consumer's informed consent, their carers and is available to them'), carers repeatedly reported being excluded and either feeling disempowered to request involvement or having to 'demand' it. Given the reported problems with access and limited services available in the community, practices which involve carers to assist with the delivery of care and achieve the best possible outcomes for consumers would both help recovery and protect many rights of people with mental illness.

As a carer I was invisible to the medical profession. We are a silent workforce. Carers should be recognised as collaborators of care and if we were recognised in this way then everybody would benefit. If I had my caring role again, I would not be so disempowered, I would now know exactly how to speak to that neurologist who disregarded me before. I would say to him that he should speak to me, I am the wife and I know what's going on with my husband.

(Carer, Wife, South Australia, Adelaide Forum #1)

...by last month was agreeing to return to Adelaide on the proviso that he live with me for the time being. He had spent most of 2003 in hospital and had been discharged into the community in January 2004. He had been placing himself at high risk even though he was on a Community Order. I was aware of the difficulties inherent in living with [X] but I readily agreed as he had been out of contact over many months ... to my amazement both psychiatrist and worker left without having exchanged a single word with me about my son. Soon after I found him snoring very loudly and saw a bottle labelled Diazepam 5 mg (10 tablets) of which five were missing ... There was no discussion of a care or management plan, assessment, follow up visit or the medication which had been left ... The visit totally disregarded my role as a carer in extreme circumstances.

(Carer, Mother, South Australia, Submission #279)

...we had to demand to be involved.

(Carer, Family Member, South Australia, Adelaide Forum #2)

...she now lives with us ... and we must admit it is very calm now and working. We have been very lucky as she now has an excellent doctor in Dr [X] whom we think genuinely cares for her welfare and has always involved us in any decision both in her welfare and of her son ... So in finalising We would say in the beginning we had an up hill struggle with the services who we believe did not really or fully comprehend our needs and dismissed our phone calls as just whingeing but we were totally ignorant of this problem and needed as much help in dealing with it as our daughter did but in a different way, several times we had the crisis team out only to be told to our faces, yes she is sick and needs treatment, then they went away leaving us to deal with a totally psychotic person and we have had no training on how to deal with this. If this letter is of any help we are pleased but up until we got a doctor who cared we were totally annoyed with all the promises and false information.

(Carers, Parents, South Australia, Submission #72)
6.4.11.4.3 Services for refugees and newly arrived immigrants

Standard 11.4.8 states: 'The MHS ensures access to a comprehensive range of treatment and support services which are, wherever possible, specialised in addressing the particular needs of people of ethnic backgrounds'. With regards to this, additional services for refugees and newly arrived immigrants were mentioned.

Need for additional services for refugees particularly those who have experienced severe traumas.

(Clinician, South Australia, Murray Bridge Forum #14)

It's particularly difficult for newly arrived immigrants in South Australia to access mental health care.

(Anonymous, South Australia, Adelaide Forum #12)
6.4.11.4.4 Lack of services for people with mental illness and drug and alcohol problems

I have previously investigated how our mental health services deal with clients who have drug and / or alcohol dependencies in addition to mental health problems, and I am concerned that this group seems particularly likely to fall through the gaps in the system. I will continue to lobby the Government to improve services in this area, particularly in terms of providing greater resources for institutional and community-based mental health care and support for families dealing with mentally ill family members.

(excerpt from a letter from Kris Hanna MP, Member for Mitchell)
(Carer, Mother, South Australia, Submission #195)

As noted above in this letter from a Member of Parliament and below, from the Health and Community Services Network, Murray Mallee Strategic Task Force, this gap in service provision is well documented. Standard 11.4.7 however states: The MHS ensures access to a comprehensive range of services which are, wherever possible, specialised in regard to dual diagnosis ...'. In the notes to this Standard, this includes dual case management with alcohol and other drug services.

It is well documented that substance abuse, including polydrug use, amongst people suffering from mental illness is extremely common. Yet mental health services and drug and alcohol services remain separate. Some residential mental health programs require participants to be drug and alcohol free before they are eligible.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

The other thing that concerns me is the substance abuse problem. There is an increasing problem for parents of children with dual drug and alcohol and mental health problems. These problems often start in Glenside when young people are first admitted - they get exposed to illegal drugs there and they start taking them.

(Consumer & Advocate, South Australia, Murray Bridge Forum #8)

The youth health sector has for many years highlighted the need for a dedicated youth detoxification program focusing on young people. Generalised detoxification services such as Warinilla are often reluctant to accept young people as inpatients due to concerns around contamination. In recent years the Women's and Children's Hospital began a small program focusing on youth detoxification in response to demand; however, an expanded and dedicated youth detoxification service is urgently needed. Similar youth specific services already exist in Victoria, Queensland and Western Australia. YACSA envisages that such a service would in the first instance support 11 to 16 year olds (with scope to encompass up to 18 years), comprise six to eight beds with a nursing component, visiting general practitioner and a staff team to manage residential and recreation support and to provide psycho-social support (case manager, youth workers, psychologist). Such a service would ideally be located in a publicly owned house adjacent to a public hospital, such as the Women's and Children's Hospital, in order to enable quick medical response. A service of this kind is also consistent with the Government's strategic directions for future drugs policy, specifically with regard to 'strengthen[ing] support' and 'timely and effective treatment', as outlined in its response to the South Australian Drugs Summit, and would fulfill Labor's promise through its Platform for Government to "review treatment and support services for young people dealing with [drug and alcohol] issues and examine the feasibility of establishing an adolescent residential treatment facility."

(Youth Affairs Council of South Australia, South Australia, Submission #38)

The Health and Community Services Network, Murray Mallee Strategic Task Force, have made the following recommendation with regard to this vulnerable group of consumers:

Recommendation: That programs be developed that will take a holistic approach to people who suffer mental illness and who also depend on drugs and self medicate to cope with life.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)
6.4.11.4.5 Lack of services for people with physical disability and mental illness

Included in Standard 11.4.7 with regard to the delivery of services to people with dual diagnosis are people with other disability. One consumer advocate expressed concerns that this group of people experience difficulty in accessing services and are being discriminated against. Standard 11 (Access), states that 'The MHS ensures equality in the delivery of treatment and support regardless of ... physical or other disability' and Standard 11.1.7 states 'The MHS, wherever possible, is located to promote ease of physical access with special attention being given to those people with physical disabilities ...'.

I am here representing people with physical disabilities who also have a mental health problem. Trying to get access to hospital services is problematic. An official complaint has gone in to the Human Rights and Equal Opportunity Commission regarding this matter and it's happening throughout Australia. The Australian Cerebral Palsy Association can testify to this. We are concerned that something be done about this situation. We have a saying ... "We're consulted to death but we're still dying!"

(Consumer and Advocate, South Australia, Adelaide Forum #3)

I was recently at a funeral of a friend and a large number of mental health workers came to his funeral. The problem is that they weren't there for him before his funeral when he really needed them and they haven't been back since his funeral! The funding is extremely important, we need adequate funding for appropriate services.

(Consumer and Advocate, South Australia, Adelaide Forum #3)
6.4.11.4.6 Lack of mental health services for the aged

Older people make up about 14% of South Australia's population but more than half of the admissions to hospitals. The frail aged are a special needs group in our community and are frequently found to experience high prevalence mental disorder - this is important in residential care where rates are higher than found in the community. These high-prevalence disorders are the dementias, delirium, depression and behavioural disorder at a level that cannot be addressed by acute psychiatric services, but which lead to significant distress to the person or those providing their care.

(Academic, South Australia, Submission #187)

Concerns were raised with regards to the many difficulties in providing services to this age group. Standard 11.4.3 ensures access to a 'comprehensive range of treatment and support services which are, wherever possible, specialised in regard to a person's age and stage of development'.

In this group -and particularly with the 70+ group -we see a blurring of the boundaries between physical and mental function.

(Academic, South Australia, Submission #187)

Given that the issues arise in community and residential (as well as acute inpatient) settings, the sources of funding ought to include the Commonwealth and State government departments of health, ageing and mental health. The service needs to be developed as a partnership of the acute, aged/community sectors and GPs.

(Academic, South Australia, Submission #187)

Disturbing behaviour was cited as a difficulty both in terms of settings where treatment is provided for other patients and staff (e.g. acute care and mix of consumers, aged residential setting) and discharge planning.

The evidence suggests that people with mental or behavioural disorders are likely to be seen as difficult and complex with the result that they are less likely to receive adequate or appropriate care. Disturbing behaviour is obviously not restricted to the nursing home setting ... These behaviours are common and they have a significant impact on both the quality of care and the carer burden / burnout.

(Academic, South Australia, Submission #187)

...behavioural disorder and psychological symptoms associated with dementia are common in acute care settings (with implications for length of stay and discharge planning as well as issues for care provision) and residential care (where they are associated with increased dependency and higher care costs). They are not always well managed. (Brodaty, Draper & Lee-Fay 2003)

(Academic, South Australia, Submission #187)

People in acute hospitals with behavioural and psychological symptoms of dementia are more difficult to discharge because of difficulties in placement (Draper & Luscombe 1998). This is often due - quite reasonably - to the reluctance of residential care facilities to accept people whom they feel they may not be able to manage.

(Academic, South Australia, Submission #187)

Whilst at the Consultation I also noticed that the elderly with mental illness were not mentioned?? I would like to highlight the urgent need for accommodation such as nursing homes / hostels here in SA and the lack of mental illness understanding within the mainstream nursing homes (they do have understanding of dementia and alzheimers though). There is also a lack of psychiatrists that specialise in this arena here in SA.

(Anonymous, South Australia, Submission #61)
6.4.11.4.7 Lack of services for people with personality disorders

I am particularly concerned for those people with personality disorders because they are not getting any help.

(Social Worker, South Australia, Adelaide Forum #20)

Clinicians and service providers also raised concerns about the lack of services for people with personality disorder. Specifically, evidence was presented indicating the positive results that can be achieved both at a personal and societal level from providing treatment to people with this mental illness.

We get referrals from the prison and one of the big problems is that people are not getting access to accommodation and support especially those people with borderline personality disorders.

(NGO Service provider, South Australia, Adelaide Forum #21)

...draw the Committee's attention to research highlighting the cost benefits of implementing best practice strategies in the treatment of Borderline Personality Disorders. Borderline Personality Disorders is a serious mental illness that affects 2% of the general population, resulting in a suicide rate of 10% and a dependency on social security supports extending from 19-years old through to their mid 50's. This group constitutes around 20% of the population admitted to psychiatric inpatient services*. The results of a NSW study (1999) indicated that the cost of 12 months treatment for a sample of 30 (involving only inpatient, ambulatory, diagnostic and pharmacotherapy services) was $765,789. If instead, this same sample was provided twice weekly therapy sessions, then a saving of over $500,000 was made (this figure includes the cost of therapy)**. (*DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition 2000 pp 707-708; **Hall J, Caleo S and Stevenson J. Economic Analysis of Psychotherapy for Borderline Personality Disorder Patients. CHERE Project Report 9 Discussion Paper, June 1999) (author's emphasis)

(Anonymous, South Australia, Submission #239)

...preliminary results of long term outcomes would indicate that most return to work. The implication of this would be that a percentage of this population would move from receiving the Disability Pension into the work force/tax paying population. That is, they would be adding to Government funds not drawing on it. ...We believe that two conclusions can be reached: Evidenced-based programs indicating best practice models in the treatment of Borderline Personality Disorder are available and underutilised. These are available for both the in-patient and community-based setting. If utilised, they can lead to significant cost benefits to local and state government revenue. (author's emphasis)

(Anonymous, South Australia, Submission #239)
6.4.11.4.8 Lack of services for people with eating disorders

I have personal experience in telephone helpline and lobbying and support for people with Eating Disorders ... I can relate to what [Y] said about the lack of services available - often the only service option is to go to Flinders Hospital. We hear stories of girls being told they need to lose more weight before they can get admitted - services are very restricted. We need a holistic approach and I'd love to see that developed further.

(Clinician, South Australia, Adelaide Forum #7)

Clinicians, service providers and consumers expressed concerns about the lack of availability and quality of treatment and support services for people with eating disorders.

The Blackwood program ... is under high demand, usually carrying waiting lists of several months.

(Service Provider, South Australia, Submission #233)

Also there is a lack of acknowledgement of young teens (12 years and older) of having a real diagnosis. Other co-morbidities also don't get acknowledged, particularly anxiety. There are lots of health issues for our client group ... the response from primary care isn't there and we know that a good response in the early stages of an eating disorder will help improve longer-term outcomes. But the reality is that the response isn't good and there aren't enough psychologists or counsellors.

(Clinician, South Australia, Adelaide Forum #8)

...I am very disappointed by the quantity, quality, variety, specificity and expense of the inpatient and outpatient treatment available to (public) mental health patients, particularly for sufferers of eating disorders. Eating disorders (and depression) are extremely debilitating and can be fatal. It is no way to live. I urge the government to improve public access to quality, specific help for eating disorders and depression.

(Consumer, South Australia, Submission #158)

It just felt like I was bashing my head against a brick wall. After 3 days in the Psychiatric Ward, I was put on the Eating Disorders 2-week assessment program. I experienced the most laughable thing during this time; I was not able to see a doctor or physiotherapist in hospital for four days, even though I was experiencing considerable back pain, because it was Easter! This meant I could not even get painkillers stronger than asprin! During the 2 weeks, I saw nurses, student doctors and student psychiatrists reasonably often, but saw qualified doctors rarely, and the only time I got to see the psychiatrist was for about 8 minutes when I was being discharged! What a joke! I did not even receive any helpful "assessment" or advice out of the program.

(Consumer, South Australia, Submission #158)

South Australian mental health resources are dangerously inadequate - particularly for those people requiring inpatient treatment and intensive care over a longer period of time, for such illnesses as eating disorders. While only in my early 20's, I have been tangled in an unsupportive mental health system for nearly 10 years - during which time little (if any) long term progress has been made. I have no hesitation in saying that a more supportive system could well have seen me in and out in a matter of years, rather than still utilising the seemingly ineffective treatments available to me through sheer desperation ... The system may have saved me in the short term, but it has done nothing to improve my quality of life in the longer term. My fear is that I will remain in the system, and never break free of the shackles mental illness has placed on me. Nothing would please me more than to legitimately earn my way out of the system. In order for that to happen though, I need to be provided with viable treatment options.

(Consumer, South Australia, Submission #215)

Despite having private health insurance, in the absence of a private facility to effectively treat people who suffer from eating disorders, I have been forced to add to the burden already placed on the public hospital system - where there is an eating disorders treatment program (albeit suspectly effective). Brief inpatient treatments of 2...4...6 weeks are seemingly not successful (as can be seen by the high readmission rate of patients to the Weight Disorder Unit at Flinders Medical Centre).

(Consumer, South Australia, Submission #215)

As you would know, eating problems are a high prevalence disorder among young people and are also the most fatal (~15%), particularly anorexia, even compared with depression and schizophrenia. Of course, eating problems commonly co-occur with depression and anxiety ... Although in-patient facilities are not a preferred way of dealing with anorexia, when the person's life is severely compromised they are inevitable, provided there are places/beds available. The major dilemma I am witnessing is the limited capacity in SA (really Adelaide as there are only metro-based programs), to provide an appropriate youth-friendly and family/carer-inclusive service ... The only program with a good reputation for offering such a service is the private Blackwood Hospital program, although if people's physical health is so poor as to require nutritional rehabilitation/restoration via medical intervention then the person must go to WCH [Women's and Children's Hospital] or FMC [4G Psychiatric Ward of Flinders Medical Centre].

(Service Provider, South Australia, Submission #233)

By working on 'networking' we have increased access to people who, as a result of personal experience, have skills knowledge and insights which could, accompanied with other work experience they have, provide a very valuable resources which could be of great benefit to people recovering from eating disorders. I would love to see appropriate people make up a new workforce of non clinical community mental health workers; people who, as a result of personal experience and including their work and study qualifications, work to fill the gap in services that exists between GPs diagnoses and hospital admissions.

(Anonymous, South Australia, Submission #44)

I wish to add, that I feel extremely positive about and believe that there are many women (and men) with eating disorders who could recover far more quickly than they presently do. I believe that worked with in the 'correct' light, eating disorder issues could be broken down and worked with in such a way that we see very positive cultural (social) changes as well as health changes in the future. There are many inspired people who wish to support these changes but within the current governing framework (rules and regulations) this process is slowed down or prevented.

(Anonymous, South Australia, Submission #44)
6.4.11.4.A Community living

The MHS provides consumers with access to a range of treatment and support programs which maximise the consumer's quality of community living.

Under this Standard, submissions and presentations indicate concerns about:

  • the lack of family-centred approaches and support services;
  • lack of self care and living skills programs;
  • lack of community support services to maximise opportunities to live independently; and
  • lack of support for children of parents with mental illness.
6.4.11.4.A.1 Lack of family-centred approaches and support services

Many reports were received from consumers, clinicians and carers describing the incredible strain that has been placed on families, in particular, on children of parents with mental illness. The lack of access to family-centred approaches and support groups was repeatedly mentioned (as stated in Standard 11.4.A.12). Also, the lack of access to other support services (e.g. leisure, recreation, education, training, work, employment, respite, home and community care) also contributed to this. Strain was also seen to emanate from discriminatory remarks made from members in the community towards family members, a general lack of community acceptance and increasing social isolation (family and individual).

I have been mentally ill for 10 years. There's no support for my children or my wife. Because my kids don't get any support, in fact they get teased about having a father who is mentally ill, they then come home and take it out on me; tell me I'm nuts or I'm a loony. Schools need to provide my family, my children with support. We also need a support group for my wife / carer. Perhaps something like this could be run through the hospital.

(Consumer, South Australia, Murray Bridge Forum #1)

Children who have parents with a mental illness are not having their needs met. Sometimes those kids are removed from the care of their parents, instead of supporting them in their homes.

(Clinician, South Australia, Murray Bridge Forum #14)

The system has continually failed [X] from early childhood. It has failed me as a parent, and I know I must keep fighting while I can. I know there are mothers and sons out there, but I feel very lonely and drained. I only have short bursts of happiness knowing my son is living such a horrendous life with no way out.

(Carer, Mother, South Australia, Submission #195)

I run a monthly support group for 40 or 50 people. Many have sons or daughters with mental illness. These people need long-term supported housing for their children. They cannot continue providing all the care without support and they can't wait for support to occur every 2 weeks.

(Carer, South Australia, Adelaide Forum #18)

Consumers can support other consumers but they also need access to resources to be able to do this.

(Carer, South Australia, Adelaide Forum #18)

There is insufficient respite for carers of people with mental illness.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)
6.4.11.4.A.2 Lack of self care and living skills programs

As alluded to above by a carer, with the current lack of supported accommodation, many consumers are forced to return to live with their families. In many instances, this placed intolerable strain on families as they waited for places to become available. Additionally, the lack of self care and living skills programs meant that consumers are also not able to gain the necessary skills to live independently and move out.

When people have been severely mentally ill they do forget the basic hygiene and basic survival skills they once had so they need help to relearn these skills and this involves someone coming into their home to help relearn how to make soup and other things and how to clean the house. A lot of people don't have families that can help them in this way.

(Consumer, South Australia, Murray Bridge Forum #7)

As indicated by one consumer, some people have carers who can assist with this, but many do not. An NGO employment service provider who provides cleaning services indicated the living conditions and result for consumers who have been unable to access such programs:

We are now seeing houses that are nothing short of disgusting! These houses are occupied by people who have been discharged from psychiatric institutions and they live like dogs because there's no follow-up care for them, they are not taught any basic living skills and most don't even know how to cook for themselves.

(NGO Employment Service Provider, South Australia, Adelaide Forum #19)

Living skills and self care programs would enable consumers to live with dignity in society and are seen as critical. Standard 11.4.A.13 states: 'The MHS provides a range of treatment and support which maximises opportunities for consumers to live independently in their own accommodation' and 11.4.A.2 states: 'Self care programs or interventions provide sufficient scope and balance so that consumers develop or redevelop the necessary competence to meet their own everyday community living needs'.

6.4.11.4.A.3 Lack of community support services to maximise opportunities to live independently

Coupled with the lack of available programs for consumers to learn the necessary skills to live independently, is the lack of services available to assist with domestic care and general support.

Mental Illness not recognised as a disability by HACC! Funding for service delivery not available.

(Consumer Advocate, South Australia, Submission #136)

People with a mental illness are discriminated against. People with other health problems who have been in hospital will get Domestic Care but not so for people with a mental illness - surely they should get the same sort of help.

(Consumer, South Australia, Murray Bridge Forum #7)

Consumer advisory group in the process of developing a service to provide support services to people with a mental illness / families & carers. On numerous occasions they have encountered animosity from some staff / service providers who are questioning their ability to provide such a service.

(Consumer Advocate, South Australia, Submission #136)

Social support also needs to be extended. These people have suffered at different times from inappropriate drugs or the amount of drugs prescribed; they would like more information about drugs and their side-effects which can cause stigma. A huge focus of their life is their mental illness as they are constantly being defined in relation to it and there are few options of independent living or employment or to socialise with people who do not have a mental illness. It is impossible for them to get a job in the private employment or housing market due to stigma. False friends often rip them off financially or involve them in crimes without their knowledge.

(Family Member, South Australia, Submission #6)

There is a lack of services in country regions and in Murray Bridge South Australia there is local GP's the general hospital, and SWANPORT HOUSE COMMUNITY PROJECT. The latter provides opportunity to do social activities on a regular basis and receive individual support and counseling [sic] as required. The service is struggling to cater for 40 mentally ill adults with limited funding and only one full time worker and one part time worker. There are many people on a waiting list who do not receive any support which is unacceptable. There is no capacity to expand the service is none the less as good as it can be but is insufficient in its present form. There is no choice or alternative services and no specialised services for employment or children of mentally ill adults.

(Consumer, South Australia, Submission #77)

Families are left to fend by themselves with no social workers or mental health workers working outside the hospital. (Kahlyn, Glenside, Murray Bridge Soldiers Memorial Hospital.)

(Consumer, South Australia, Submission #77)
6.4.11.4.A.4 Lack of support for children of parents with mental illness

The lack of programs and services to support children of parents with mental illness were also highlighted. Standard 11.4.A.12 states: 'The MHS ensures that the consumer and their family have access to a range of family-centred approaches to treatment and support'. This support would assist parents with mental illness to continue to live in the community and fulfil their role as a parent and keep the family unit as functional as possible. However, as seen in the comment below, this is not always the case:

We ... feel that Human Rights breaches are occurring every day. We highlight the following - When an adult presents unwell and is diagnosed. the question is not necessarily asked "Are you a parent?", "How old are your children / how many do you have?", "What age are they?". The Adult Mental Health Sector has been negligent for many, many years in this arena and there is a lack of consistency. Some adult mental health workers have spoken openly of their concern for their clients children and not followed up??? (usually because of lack of support services in the community). We do not suggest for one moment that a parent with a mental illness is a poor parent but what we do say very clearly is that when a parent is becoming unwell, is unwell and then released from hospital / clinic these times can be very challenging not only for the adult structure of the family but also for the children. A parent may go home to a family of two small children with not support - parenting is difficult at the best time, imagine going home to two small children and having to cope with your mental illness, medication, doctors appointments etc and having no support?? We refer you to Article 16.3 - Universal Declaration of Human Rights to highlight the lack of protection by society and state.

(Anonymous, South Australia, Submission #61)
6.4.11.4.B Supported accommodation

Supported accommodation is provided and / or supported in a manner which promotes choice, safety, and maximum possible quality of life for the consumer.

Under this Standard, submissions and presentations indicate concerns about:

  • the general lack of supported accommodation;
  • the need for interim (step up and step down) accommodation;
  • lack of supported accommodation options for young people; and
  • the lack of support for providers of supported accommodation.

6.4.11.4.B.1 Lack of available supported accommodation

The lack of supported accommodation was cited on several occasions as being a reason for 'revolving door admissions' and consumers remaining unwell unnecessarily for extended periods. The lack of supported accommodation in rural and regional areas was particularly noted. The lack of such accommodation options, combined with the lack of community based treatment and support services, places intolerable strains on families.

The lack of supported accommodation in Murray Bridge results in people leaving hospital then returning 3 or 4 weeks later as the system is overloaded.

(Clinician, South Australia, Murray Bridge Forum #5)

In my country town there is supported accommodation but not for people with a mental illness.

(Carer, Consumer & Advocate, South Australia, Adelaide Forum #5)

There is a lack of supported accommodation and supported residential facilities for those with chronic mental health problems living in the Murray Mallee. This means extra pressure on carers and / or that those with a mental illness are living in isolation without day to day support.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

Our complaints workers are dealing almost entirely with mental health related complaints. We are also very concerned with the lack of appropriate supported accommodation facilities for people in South Australia. There are old boarding houses that are privately run but they are the dumping ground for people with a mental illness and these places get no funding. People are sent there in taxis from hospital when these facilities don't have the capacity to care for these people.

(Anonymous, South Australia, Adelaide Forum #14)

On the 6/8/04 my son rang distressed saying he had to have somewhere permanent to live if he had a C.T.O. [Community Treatment Order]. Apparently it was suggested to him an alternative possibility would be a backpackers hostel. He asked to live with us again ... Again whilst discussing suitable accommodation my son suggested he sleep at a friend's on a couch. I told the nurse this was not an option. My son then suggested sleeping in his car, something he did for periods prior to his hospitalisation. Again I expressed the belief that this is not conducive to his mental and medical rehabilitation. I was taken aback at her suggestion that living in the car is an option, it is an alternative lifestyle that some people like. This I believe is not an option for a vulnerable person in Australia in 2004. We have seen no evidence of my son being able to function alone.

(Carer, Mother, South Australia, Submission #11)

My nephews are living with their father, and have not been able to successfully maintain housing independently, or employment. The recreational club that one of them goes to has been called a 'lifeline', however transport to the centre has been cut entirely, and the service itself has been cut (e.g. from 5 days to 3 days). Most people who attend the centre are over 30, and living with their parents in the community. The boarding house option was tried by one nephew, but it offers absolutely no privacy and due to this one is drawn into conflicts.

(Family member, South Australia, Submission #6)

Recommendation: That governments give priority to providing supported residential facilities as well as supported accommodation in the community for people recovering from mental illness, including those in rural and regional areas.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

[Recommendation] Urgent action to redress the lack of supported accommodation, with development of a Statewide plan and an increase in funding from 0.4% to a level sufficient to meet need.

(SANE Australia, National, Submission #302)

6.4.11.4.B.2 Need for interim (step up and step down) accommodation

Many submissions argued that a range of accommodation options were needed and that these needed to be flexible, for example, interim step-up and step-down facilities. Concern was expressed that as discharge often occurs 'far too early', an interim 'step down' facility between hospital and home would assist the recovery process:

It is easier to recover from mental illness in hospital than at home. However, the average is about 3 days, and discharge from mental health care occurs far too early. Consumers have no option but to rely on hostels for accommodation, which cannot provide proper care or suitable environments for recovery.

(Consumer, South Australia, Submission #41)
6.4.11.4.B.3 Lack of supported accommodation options for young people

After 30 years of social work practice I've entered many SRFs [Supported Residential Facilities] - starting in 1970s. I can confidently say that the Burdekin Report made absolutely no difference to the lives of these men & women, most of whom experience mental illness. Their level of physical & mental health is at the same disastrous level as homeless & Aboriginal people. If you haven't seen the SA Research paper "Somewhere to call home - Supported Residential Facilities: the sector, its clientele & its future" then you might find it informative ... Going into some of the Facilities today, I feel like they are in worse shape than in the 1970s when many were established at the encouragement of the govt to "empty out" the backwards of the psychiatric hospitals. And talking with the managers, it's clear that they do not feel that they and their residents are receiving anywhere near an adequate service from the mental health services - some do have the ear of an overworked mental health worker but not the system.

(Family Member and Service Provider, South Australia, Submission #34)

Of particular concern was the reported lack of accommodation for youth with mental illness or mental health problems. As mentioned previously in this report, the scarcity of services for this age group and inability for clinicians to intervene as early as possible often has serious long term consequences.

We're dealing with young people with their first episode of mental illness and that's quite a frightening experience. We're also really concerned for those young people with comorbid mental health and drug and alcohol problems. Who picks them up? Nobody really, they get shifted back and forth because nobody wants to deal with them.

(Supported Accommodation and Assistance Program (SAAP) Service Provider,
South Australia, Adelaide Forum #4)

I've noticed a marked increase in the number of young people with a mental illness and we're constantly asked to provide accommodation these young people but we're not funded to do that.

(Supported Accommodation and Assistance Program (SAAP) Service Provider,
South Australia, Adelaide Forum #4)

We're often getting referrals from mental health services and we often have pressure put on us to take these young people because we're told they can't come out of hospital if they don't have anywhere to go.

(Supported Accommodation and Assistance Program (SAAP) Service Provider,
South Australia, Adelaide Forum #4)

I did want to raise the issue of supported accommodation for young people with a mental illness. Our members have been reporting to us that when they have young people with a mental illness they often have behaviours which exclude them from housing. 3 years ago we produced a report. We are also advocating for a youth-specific detoxification service in South Australia - a lot of young people with drug and alcohol problems are not getting the care they need or deserve. We've sent a report on this to Human Services. And we have put a recommendation in every budget cycle and even though there has been some interest from some Ministers for further information, nothing has happened!!!

(Youth Worker, South Australia, Adelaide Forum #6)

In response to increasing concern about a widening gap in available services from the youth sector, YACSA recommends the establishment of an accommodation service specifically for young people between the ages of 12 and 18 years who are experiencing mental illness. The accommodation facility would offer specialist fully supported accommodation for up to six young people (three young women and three young men). In order to provide a comprehensive service, four full-time social workers would be co-located with the accommodation facility. The social workers would provide an outreach service to young people experiencing mental illness and their families in order to support young people to remain living at home.

(Youth Affairs Council of South Australia, South Australia, Submission #38)
6.4.11.4.B.4 Lack of support for providers of supported accommodation

According to Standard11.4.B.6: 'A range of treatment and support services is delivered to the consumers living in the accommodation according to individual need.' Listed in the notes to this Standard are crisis intervention and 24-hour access to the MHS. According to concerns expressed by one Supported Accommodation and Assistance Program service provider, crisis services were not able to be obtained and the police had to be called.

If we ring ACIS, the Assessment & Crisis Intervention Service, the response is poor, I can tell you about an incident where even an acutely unwell person couldn't get a response. I really pushed for assessment and they told me to take them to hospital so I had to call the police. Calling the police is not good for our relationship with our clients. We shouldn't have to do that.

(Supported Accommodation and Assistance Program (SAAP) Service Provider,
South Australia, Adelaide Forum #4)
6.4.11.4.C Medication and other medical technologies

Medication and other medical technologies are provided in a manner which promotes choice, safety and maximum possible quality of life for the consumer.

Under this Standard, a presentation indicated concern about:

  • the exclusive use of medication as the only treatment option;
  • the use of antidepressants for children.
  • informed consent and the use of Electro Convulsive Therapy (ECT)
6.4.11.4.C.1 Medication the only treatment option

One social worker expressed concern that there is 'no choice' being offered to consumers and effectively 'no care' being provided, just the dispensing of medication. This would also imply that the 'maximum quality of life' for the consumer could also not be attained by this method.

People are being forced to take medication and get no other care - there's often nothing else.

(Social Worker, South Australia, Adelaide Forum #20)
6.4.11.4.C.2 Concerns about the use of antidepressants for children

According to Standard 11.4.C.10 'The MHS ensures access for the consumer to the safest, most effective and most appropriate medication and/or other technology' and Standard 11.4.C.1 'Medication and other technologies used are evidence-based and reflect internationally accepted standards'. One academic also raised safety and efficacy concerns about the use of antidepressants for children and adolescents.

We are concerned that biased reporting and overconfident recommendations in treatment guidelines may mislead doctors, patients, and families. Many will undervalue non-drug treatments that are probably both safer and more effective. (Jureidini et al article also referenced)

(Academic, South Australia, Submission #219)
6.4.11.4.C.3 Informed consent and the use of Electro Convulsive Therapy (ECT)

Standard 11.4.C.3 states 'The MHS obtains the informed consent of the consumer prior to the administration of medication or use of other medical technologies such as Electro Convulsive Therapy'. One consumer expressed concern that more information about benefits and side-effects needs to be provided and that a support person or advocate should also be required to be involved in the process of obtaining consent:

This is a situation that I feel needs attention as there may be other mentally ill patients being given ECT without their informed consent and I believe it devalues me as a person. ECT gave a brief improvement and did not in my opinion solve my depression. My depression was more effectively dealt with by medication. ... I am writing this as a follow up of your visit to MURRAY BRIDGE recently. I hope this experience can be noted as I suspect many mentally ill persons may be treated with ECT without their real permission. Had I known of the memory problems which they deny exist I would not have consented to ECT. I really needed my wife or a Government person to act on my behalf in making the decision to undergo ECT. (author's emphasis)

(Consumer, South Australia, Submission #77)
6.4.11.4.D Therapies

The consumer and consumer's family / carer have access to a range of safe and effective therapies

Under this Standard, a presentation indicated concern about the limited range of therapies offered by the mental health service.

6.4.11.4.D.1 Limited range of therapies offered by the mental health service

One carer expressed concern that group therapy was not available for people with mental illness.

I am however, concerned about the lack of group therapy available to people with a mental illness.

(Carer, Family Member, South Australia, Adelaide Forum #2)

According to Standard 11.4.D.2 the MHS 'provides access to a range of accepted therapies according to the needs of the consumer and their carers'. This includes group methods. According to the notes to this Standard, the MHS should provide the therapy or refer the consumer or carer to another provider.

I am very aware of the need to work with people over the long term ... and holistically ... I am aware that this holistic approach is a considerably 'untapped' approach regarding treating people with eating disorders and mental illnesses generally. When a great percentage of the issue of eating disorders has to do with being 'cut off' from ones body - non ingestive / non invasive body work and psycho-education can play a huge part in encouraging women (and men) to adopt physical (and mental) self care techniques. It is in the communities [sic] interest to integrate these 'other' methods practice to assist people with mental health issues. In particular they need to be accessible constantly - not just financed for short periods of time.

(Anonymous, South Australia, Submission #44)

Professionals are aware that alternative and complimentary (non clinical community) services could be set up privately. However there are two things that work against this pursuit.

•  This would exclude a large majority of people who suffer from eating disorders. Regardless of the governments push to get individuals to take out private health insurance, most people do not have private health insurance or if they do, then the insurance that will cover the types of treatment needed to recover (often needed over a long term). It is wrong to exclude them from access to treatment (where there is such a great lack of it at any rate).

•  Because government does not equally recognise complimentary (and preventative) health practices within the system, it can foster suspicion about the therapeutic method used in the private system.

(Anonymous, South Australia , Submission #44)
6.4.11.4.E Inpatient care

The MHS ensures access to high quality, safe and comfortable inpatient care for consumers.

Under this Standard, submissions and presentations indicate concerns about:

  • excessive use of restraint and seclusion;
  • consumers and carers are not being informed or involved in treatment plans; and
  • impact of admission not minimised for families of consumers who live in rural and remote areas.
6.4.11.4.E.1 Excessive use of restraint and seclusion

There have been frequent recent stories of psychiatric patients being shackled in the ED [Emergency Department] at central city hospitals, inappropriate use of seclusion (for staff convenience not patient care), the use of outmoded and banned restraint holds by nurses and patients not being treated with the care and respect they deserve. In some cases, patients are being subjected to restraints and confinements unnecessarily and without proper care. I have heard one story of a female patient placed in seclusion in a hospital gown, who was menstruating and the female nurses removed her sanitary products on the grounds of safety. This is grossly unacceptable.

(Academic, South Australia, Submission #142)

Such practices would not be in accordance with Standard 11.4.E.1 which states 'The MHS offers less restrictive alternatives to inpatient treatment and support provided that it adds value to the consumer's life and with consideration being given to the consumer's preference, demands on carers, availability of support and safety of those involved'. Excessive use of restraint and seclusion infringes on many consumer rights, as described below.

When I asked patients in a research study about what they thought of seclusion, their answers were largely negative, they feel punished, humiliated, bored and scared when in seclusion. This is not quality nursing care.

(Academic, South Australia, Submission #142)

Given the scarcity of early intervention and treatment options in the community setting, consumers are often forced to reach crisis point before access to treatment is allowed and then they are 'punished' by the mental health service by the use of restraint and seclusion. The necessity to use restrictive practices would be minimised if treatment and support could be accessed earlier.

I have been writing and researching seclusion for ten years in South Australia and perceive that standards have fallen markedly since the Burdekin Report.

(Academic, South Australia, Submission #142)
6.4.11.4.E.2 Consumers and carers not informed or involved in treatment plan

The following report from an NGO service provider raises serious concerns about the lack of involvement of the consumer in the planning and delivery of treatment, non-involvement of the carer, and assessment and review procedures. Furthermore it would appear that the consumer was not informed of her rights (Standard 11.4.E.6) and many of the criteria as outlined under Standard 11.4 (Treatment and Support) were not met (e.g. Standard 11.4.9 'There is a current individual care plan for each consumer, which is constructed and regularly reviewed with the consumer and, with the consumer's informed consent, their carers and is available to them').

Upon entering the WCH (the Adolescent Ward of the Women's and Children's Hospital) Eating Disorders Program on a Friday lunchtime, having been admitted by the treating private gastroenterologist that works with the Program Team, there was no contact with the young person or her mother by the Program Director to explain the program focus and stages for 5 days (the following Wed afternoon), and only then after a direct request for this to occur by myself during a conversation on the Tuesday afternoon ... Five days is a very long period of time for a 14 year old, particularly in a hospital environment where there is no clear information on what is going to happen ... There was no proactive effort on the part of the Program staff to gain the background and context of the eating problem, or to discuss it with the family or the treating professionals.

(NGO Service Provider, South Australia, Submission #233)

At no point in this process did anyone from the Eating Disorders Team have direct personal contact with the young person and family to talk about their experiences, needs and progress, apart from the gastroenterologist. Any feedback received and used at team meeting decisions (which occurred twice / week) came from the gastroenterologist and presumably the nursing staff. Neither the mother or I were invited to any further team meetings; the main link into the team was the gastroenterologist.

(NGO Service Provider, South Australia, Submission #233)
6.4.11.4.E.3 Impact of admission not minimised for families of consumers living in rural and remote areas

Standard 11.4.E.7 states: 'The MHS assists in minimising the impact of admission on the consumer's family and significant others'. The notes to this Standard include 'support for extended family'. According to one submission, no communication or assistance was received by the family to help them understand what was happening as they could not visit personally:

When admitted to an Adelaide hospital you become distant from your family and visiting is less affordable. Again no communication from the hospital to help families adjust and understand what is happening occurs.

(Consumer, South Australia, Submission #77)

6.4.11.5 Planning for exit

Consumers are assisted to plan for their exit from the MHS to ensure that ongoing follow-up is available if required.

Under this Standard, submissions and presentations indicate concerns about:

  • inadequate planning prior to exit; and
  • discharge being used as a threat with the consumer.
6.4.11.5.1 Inadequate planning

When the inpatients return to the Mallee from a period in Glenside discharge planning is often inadequate.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia, Submission #115)

This concern raised by the Health and Community Services Network, Murray Mallee Strategic Task Force, raises concern about both the adequacy of the planning that should have occurred prior to discharge and the limited access to treatment and support services in rural and regional areas (discussed previously) which could hinder the development of such a plan. Specifically, the submission suggests that discharge plans have possibly not been developed in collaboration with the consumer (Standard 11.5.2), that understandable information about the range of relevant services and supports have not been provided (Standard 11.5.4) and that the service has failed to ensure consumers have established contact with relevant external service providers prior to exit (Standard 11.5.6).

6.4.11.5.2 Discharge used as a threat

A report was also received suggesting that discharge was being used as a threat to comply with treatment and not as part of a care and treatment plan with and agreed stage of recovery where discharge is appropriate with follow-up.

The suicidal behaviour resulted in a request for a risk assessment by the psychiatrist. Immediately after this occurred the young person was highly distressed and self-harming again. Soon after she was calmed, she then absconded from the hospital - upon recovery and return she was, understandably placed on a detention order. The psychiatrist lifted this the following day, but recommended that either the young person engaged in the complete program, or she was moved toward discharge ASAP. The mother and young person experienced this as an ultimatum.

(NGO Service Provider, South Australia, Submission #233)

6.4.11.6 Exit and re-entry

The MHS assists consumers to exit the service and ensures re-entry according to the consumer's needs.

Under this Standard, submissions and presentations indicate concerns about:

  • inappropriate discharge; and
  • lack of follow-up.
6.4.11.6.1 Inappropriate discharge

Concerns were expressed that discharge was occurring without appropriate planning and notification to either the consumer or carer, and in this instance, jeopardising the safety of the consumer. According to Standard 11.6.1, 'Staff review the outcomes of treatment and support as well as ongoing follow-up arrangements for each consumer prior to their exit from the MHS'. Standard 11.6.2 implies that both consumers and carers are notified about discharge so that they can be provided with information and are aware of 'how to gain entry to the MHS at a later date'.

Five days after this letter was written [March 2004] my son was unexpectedly and inappropriately discharged from the Royal Adelaide Hospital. I was not notified, no discharge planning was done, and a Guardianship Board Order was not sought. When I spoke to the Registrar on this last point I was told that the waiting time for a Guardianship Board Order was such that the decision was made not to apply for an order. This in relation to a man who has not been without some kind of Order since 1988 ... My son headed to the parklands and could not be found for five days. He then appeared at RAH emergency seeking admission where he claimed he had been threatened and assaulted and was being followed.

(Carer, Mother, South Australia, Submission #279)
6.4.11.6.2 Lack of follow-up

Concerns were also expressed about the lack of follow up following discharge from the mental health service. Consumers and carers reported occasions when they were left with no support or follow up care, even when such plans were referred to in the discharge summary.

Carers also reported that they had been given insufficient information to understand the nature of the mental illness and the treatment support necessary. This left carers with feelings of extreme stress and fear for the safety of their family member with mental illness and their own safety. Another carer commented that despite adequate planning for follow-up, this had not occurred and that the mental health service needs to be more vigilant. Standard 11.6.4 states 'The MHS attempts to re-engage with consumers who do not keep the planned follow-up arrangements'.

It is also apparent and of concern that follow-up had not occurred following Mr [X]'s departure from inpatient care, despite concerns in the discharge summary that future treatment may have to be provided in an intensive care setting. (excerpt from a letter from the Director of Mental health, Mental Health Services and Programs, Department of Human Services, 2004)

(Carer, Mother, South Australia, Submission #195)

After exhibiting psychotic behaviour my son spent 21 days (detained) in Glenside Hospital in March 2002. He was counselled and medicated then turned out into the community with some medication but no follow up care. Shortly afterwards he stopped his medication, reverted to his anti-social, aggressive and irrational behaviour, a state he has been in unchecked for two years.

(Carer, Mother, South Australia, Submission #11)

On discharge there is no discharge plan and the support received by the patient from the hospital ends with not even a phone call to see how you are.

(Consumer, South Australia, Submission #77)

We fear for my son's life and that of others. Currently he tells us he hears his dead father talking to him saying I, (his mother), is Satan and evil and must be killed. I believe after my son's release from Glenside in 2002 some sort of compulsory care and medication should have ensued. He should have been allocated a case worker who could assist him in decision making and support for us. We do not have the necessary skills and understanding of his problems and with the mental health system as it stands his and our prospects of positive outcomes are negligible.

(Carer, Mother, South Australia, Submission #11)

6.4.12 STORIES OF HOMICIDE AND SUICIDE IN SOUTH AUSTRALIA

I can tell you about a woman who arrived on a bus from Victoria - we tried to certify her three times one weekend. We couldn't get her certified but then she jumped off the bridge.

(Police Officer, South Australia , Murray Bridge Forum #16 )

[N]ot much has changed in the country Post Burdekin ... A few years ago (but since Burdekin) my brother in law hung himself - in his shed in a country town. This followed at least 2 prior attempts. Although he presented to the local GP at no time was he detained or in receipt of anything close to resembling reasonable psychiatric care. His poor mental health was long standing ... Everyone in town also knew about his alcohol addiction ... the treating GP had treated many of [his family] for many years ... so he knew who & what he was dealing with ... I believe that he left a note which was quite readable and was able to make the necessary arrangements to hang himself in a space some distance from his home. On his 2 previous attempts (and there could well have been more) he was unsuccessful because the methods offended his sense of not wanting to make a mess - and he didn't get any appropriate help. Given that that GP is still the dominant medical officer in town & not much else has changed in terms of service availability, I don't think my brother in law's prognosis would be any different today. Now I fear for his son's life.

(Family Member and Service Provider, South Australia , Submission #34)
© Mental Health Council of Australia 2005. Last updated 29 August 2005.
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