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Disability Rights: Not for Service - Report: Part 6_5

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

6.5 WESTERN AUSTRALIA

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

In summary, information presented in this section was gathered from 46 submissions (see Appendix 8.3.5) and presentations made at community forums attended by approximately 280 people (see Appendix 8.1). A draft copy of this report was sent to the Premier and Minister for Health for comment. An initial response from the Western Australian Government was received by MHCA but then later withdrawn. A further response from the Minister was received on 10 June 2005, too late to be incorporated into the analysis below. The response is at Part 8.4.5. An overall review of mental health service delivery in Western Australia is contained in Part 2.7.5 and is in-part informed by discussions with the WA Department of Health.

6.5.1 STANDARD 1: RIGHTS

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

Under this Standard, submissions and presentations indicate concerns about:

  • consumers not informed of their rights;
  • lack of access to interpreters;
  • problems with complaints procedures;
  • right to have others involved denied;
  • consumers' rights are not being protected; and
  • consumers not being treated with dignity and respect.

6.5.1.1 Consumers not informed of their rights

Concern was expressed that not only were consumers not being informed of their rights (Standards 1.2 and 1.3) or provided with information (Standard 1.8), many were not informed specifically that they had been made an 'Involuntary Patient' and what this meant. One academic also indicated that policies and procedures designed to ensure that consumers are provided with necessary information in verbal and written form are not being adhered to:

[X] was not informed of his rights as a Voluntary Patient and was not made aware that he had been made an 'Involuntary Patient'. This had been done without notification, oral or written. This was witnessed by us prior to [X] being placed in a drug induced sleep. He has not obtained or received copies of associated Forms relevant to this admission ... Management of [X]'s case, have violated his rights as a person with a mental illness.

(Carers, Western Australia, Submission #177)

The audit indicated that many of the nursing programmes were not running and procedures relating to other activities were not being adhered to. Events such as staff meetings, patient meetings, seclusion meetings, primary nurse meetings were erratically held if at all. Hand-over sheets, information sheets to patients, allocation files, medication sheets, information boards were rarely used and not fully replenished or when used were not completed systematically or consistently.

(Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

Failure to inform consumers of their rights. The recent review of the Mental Health Act 1996 revealed continued resistance amongst mental health workers to the philosophy and practice of informing mental health consumers of their rights, including review of orders, involuntary treatment second opinions, use of advocates. The provision of pamphlets listing consumers' rights is the most routine means of meeting the duty to inform. This is a minimum standard and considerable pressure needs to be applied to encourage verbal communication by staff about rights, at levels appropriate to consumer needs, at various times during hospitalisation or care in the community.

(Health Consumers' Council WA, Western Australia, Submission #29)

6.5.1.2 Lack of access to interpreters

For people who speak a language other than English, access to mental health care is further compounded by language and cultural barriers. These barriers compound understandings of mental health services, mental disorders, mental health problems and available treatment and support services and how to navigate the system. In many cases, a person may be socially isolated or reluctant to have family or friends involved as carers or act as interpreters for reasons of confidentiality or perceived stigma.

Evidence presented at forums and submissions indicate that many consumers from a non-English speaking background (NESB) are not made aware of their rights and responsibilities in either a written or verbal manner as required by Standard 1.3 (e.g. written material in their language or via an interpreter). This failure to inform people of their overall rights meant that consumers were specifically unaware of their right to have access to an accredited interpreter. This problem was compounded if the information regarding the availability of interpreters was not available in the consumer's first language (Standard 1.7).

Additionally, in some cases it appears that health professionals are also not aware of the right of consumers and carers to have access to accredited interpreters or alternatively they are specifically denying consumers and carers this right. This was highlighted by a service provider attending the West Perth Forum with regard to refugees:

The lack of interpreters is a real issue. Many of our people don't have carers, they are socially isolated and they have problems with the language. But they are told by many practitioners that they don't work with interpreters so they can't access adequate care.

(Service Provider, Western Australia, West Perth Forum #36)

Interpreter use of people with limited English. The Health Consumers' Council has assisted a Macedonian mental health consumer who was challenging the actions of mental health services to require him to submit to medication and involuntary hospitalisation. The clinical consultation during which the decision was made to place the consumer on an involuntary order occurred without an interpreter. We include an Advocacy report produced at the time of this consultation that highlights our concerns about the failure of mental health service clinicians to engage interpreters. Specific comment: The engagement of an interpreter should not be optional where action under the Mental Health Act is likely or possible.

(Health Consumers' Council WA, Western Australia, Submission #29)

This also suggests a failure of service providers to understand the repercussions of the refusal to engage interpreters to treat refugees (Standard 7 - Cultural Awareness). As mentioned, many refugees are socially isolated and lack the necessary family and social supports to assist them through their illness. Also, language barriers and cultural barriers may also impede help seeking behaviour. For this particularly vulnerable group of consumers, to have overcome all these issues and then be turned away could result in no further attempts being made to access alternate service providers or receiving inadequate care.

6.5.1.3 Problems with complaints procedures

Carers who had used the complaints procedure reported feelings of anger with the process, of being ignored or their concerns trivialised. As the following quotes highlight, carers described experiences that were generally unsatisfactory, and none described the complaints procedure they dealt with as 'easily accessed, responsive and fair' (Standard 1.10):

Three months later he succeeded in killing himself. I was so angry at having been so consistently 'fobbed off' that I went to the mental health place in Bunbury and complained and the lady I spoke to said. "These things happen". As if it simply wasn't important.

(Carer, Wife, Western Australia, Submission #96)

...even numerous complaints to the WA Medical Board have been dismissed with such statements as 'time lessens the memory' ... sure, after they kept fobbing off meetings with them and letting time lapse. I went to every viable person in Perth only to crash into brick wall after brick wall. [Y], Head Pysch for the state, told me I was just an emotive mother...too right I am! [Z], the shadow Health Minister at the time did what she could and in the Hansard Report this shows her attempt. At least she tried. [W], the Premier wrote me letters with pretty headings and passed the buck and did nothing.

(Carer, Mother, Western Australia, Submission #103)

...son who was sedated for 20 hours awaiting a psych review and transfer to hospital ...I supported this family in the process of making a complaint about the whole issue ...They made written complaint to [Y] at the Office of the Chief Psychiatrist. They then travelled to Perth for a meeting with [Y] with written permission from their son to discuss the issues. They also sent the letter of complaint to various other organisations and the local member. Within a few weeks they received an invitation to [Z]'s office (local MLA) with representatives from SWAHS [South West Area Health Service]. They attended this meeting but once again they were not offered any acknowledgement of their son's breach of rights or an apology. They have now received a letter from the Office of Health Review thanking them for their concerns and requesting authorisation forms to be completed. This family, after 3 months and no signs of resolution, to be now asked to initiate further engagement with another, are understandably angry.

(Family Support Worker, Western Australia, Submission #177)

Whilst this husband wrote to the person in charge of the service on 18 May and I lodged a formal complaint on his behalf through the appropriate channels on 24 May he has still not received any response [as at 6 July 2004].

(Carer Advocate, Western Australia, Submission #339)

Failure to have in place a system which enables consumers, their families and carers to make complaints confidentially and ensure that complaints procedures are adhered and responded to, weakens this right and fails to provide a mechanism by which to 'improve performance as a part of a quality improvement process' (Standard 1.12). These concerns indicate that the complaints procedure is obstructive. It is apparent that in some instances the process does not allow for the identification of single or systemic failures, and thereby is failing to allow for personal redress or systemic improvement. For consumers and carers, information about the complaints process also needs to contain clear references to the fact that advocates or other support people are available to assist them to voice their concerns:

...I respectfully request you to make representations to the Area Director of Mental Health and the Area Chief Executive Officer such that the chronic bed shortage problem and the absence of readily available emergency beds are both satisfactorily addressed in the interests of our patients and their carers - people who are often unable to advocate for themselves. (Extracts from letter to Director of Community Mental Health Programme)

(Clinician, Western Australia, Submission #24)

6.5.1.4 Right to have others involved denied

Concern was expressed that consumers are not being made aware that they have a right to have 'an independent advocate or support person with them at any time during their involvement with the MHS' (Standard 1.6). This has resulted in support people, including requested service providers, explicitly being refused involvement when consumers have specifically requested their co-attendance:

I made an appointment to see the psychiatrist outside of school hours so that my wife could attend too. I was told 'you are the patient' and they did not approve of my wife being at the appointment. I need the support of my wife as I always have to discuss the appointment with her afterwards as I am unable to remember it all and it helps me to understand things better. I was disturbed by the attitude of this person. I was asked 'do you want the appointment or don't you?' ... I said 'No'.

(Consumer, Western Australia, Geraldton Forum #72)

My brother also has an intellectual disability as well as bipolar disorder ... DSC want to handball him to Mental Health Services and visa versa. I have had to apply for guardianship of my brother in order for the mental health professionals to hold any sort of discussions with me ... the person (Me) who supports and follows his medical care and history, has been until now unable to speak with doctors to share valuable, timesaving, costsaving information that would support my brother more effectively with his care.

(Carer, Sister, Western Australia, Submission #101)

6.5.1.5 Consumers' rights are not being protected

Overall, many consumers, carers and advocates expressed concern that during their involvement with the mental health service their rights were being ignored. In particular, concern was expressed that the Mental Health Review Board is failing to protect the rights of people with mental illness and processes to support the proper functioning of the Board are also being curtailed. Problems were also highlighted with regards to the rights of people with mental illness and guardianship and administration orders:

I heard you say that Australia does not have a bill of rights but surely there is legislation (or needs to be) for basic support for long term survival of any person in our society.

(Carer, Western Australia, Submission #163)

The Review Board has failed mental health consumers to a huge degree. There is a culture of custody and control which is prevalent in WA. What we have at the moment is a mental health system that's taking money away from non-secure beds to secure beds. Part of the culture of control is the resistance to addressing a person - civil liberties. The Mental Health Review Board as a mechanism has failed us in WA. It does not use the powers.

(Consumer Advocate, Western Australia, West Perth Forum #36B)

The hospital has reduced the Ward Clerk hours, which leaves her unable to provide the time needed to do the paperwork to comply with the Mental Health Act. Often when a patient is to have a review by the Mental Health Review Board, there is no paperwork ready, no psychiatrist in attendance and no report by the treating psychiatrist.

(Nurse, Western Australia, Submission #55)

Mental Health Review Board (MHRB) fails to uphold human rights of mental health consumers. The MHRB has consistently failed to work to the reasonable extent of the scope of its powers, by testing the attitudes and practices that lead to detention and forced treatment of consumers. The MHRB is widely regarded by mental health consumers with experience of the system as not being worth the effort of contacting. Reviews are routinely limited to 20 minutes, psychiatrists' reports are taken on face value and rarely challenged, procedural fairness is seen by most consumers and advocates as completely absent.

(Health Consumers' Council WA, Western Australia, Submission #29)

Guardianship and Administration orders to readily applied to mental health consumers. ... Once an administration order has been made, it is extremely difficult to have it set aside and there is no agency or body that is able to assist consumers to approach the GAB on this matter.

(Health Consumers' Council WA, Western Australia, Submission #29)

6.5.1.6 Consumers not being treated with dignity and respect

Concern was expressed that consumers are often not being treated with dignity and respect:

All we want is our human rights, to be treated with dignity and respect - we all want that - to be respected. I can't help speaking in this passionate way.

(Consumer, Western Australia, West Perth Forum #37)

We are often required to transport these people but they are not criminals, they are ill.

(Police officer, Western Australia, Bunbury Forum #9)

Our son had done no wrong and as a mentally ill person deserved to be treated with dignity, care and understanding not to be confronted by police.

(Carer, Western Australia, Submission #175)

Police are routinely used by mental health services staff to accompany them on home visits and transport consumers to authorised hospitals for assessment. The attendance of police indicates a foregone conclusion by mental health staff that an order will be written out for the person to go against their will for assessment. Use of police shows the consumer and their neighbours that mental health staff presume the person to be dangerous and unpredictable ... Use of police in company with mental health service staff almost always leaves consumers feeling invaded in their own home and neighbourhood, treated like a criminal, presumed to be dangerous and with no regard given for anything that they may say on their own behalf..

(Health Consumers' Council WA, Western Australia, Submission #29)

Failure to inform consumers routinely of the designation of a practitioner as Psychiatrist, Registrar, Medical Officer, and leaving the consumer in the dark about what to reasonably expect from the person before them.

(Health Consumers' Council WA, Western Australia, Submission #29)

6.5.2 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:

  • excessive use of physical restraint;
  • lack of response to family concerns of danger;
  • problems with use of security guards with inpatients;
  • unsafe hospital and supported accommodation environments;
  • safety concerns for children and youth with mental illness;
  • lack of trust in MHS to ensure safety for consumers and the community; and
  • occupational health and safety issues.

6.5.2.1 Excessive use of physical restraint, sedation and armed escort

Despite continued assurances by the WA Government that there are sufficient services to ensure the safety of people with mental illness and the community, submissions suggest the Government's current focus on containment and control has failed to deliver 'safety' for people with mental illness, families, carers or the community. Instead, submissions documented excessive use of physical restraint and sedation, unnecessary involvement of the police, failure by services to respond to requests of assistance by both consumers and carers, lack of access to services when crises arose and unsafe environments within treatment settings. These concerns were raised equally by consumers, carers, clinicians and service providers:

In Esperance ...If consumers need acute care they have to be taken to a GP and then tranquilised and strapped to stretcher to be transported to Perth. I was told when I was suicidal to drive myself to the city.

(Consumer, Western Australia, West Perth Forum #45)

Consumers are driven in the back of paddy wagons - three day trips - from Kununurra to Perth. The artificial geographic boundaries create huge problems for people needing care.

(Carer, Carer, Western Australia, West Perth Forum #43))

I had an incident a while ago when I went to hospital in Bunbury, I was put aside (waited) a couple of hours - I wanted to go home but the hospital wouldn't let me go. I finally went home and a few hours later the police came to take me back to the hospital. I went willingly and saw the doctor who said I needed an injection. I was threatened that the police would hold me down while I had the injection so I agreed to have it. After they injected me I was taken to Graylands Hospital in Perth but nobody informed my family of my admission to Graylands.

(Consumer, Western Australia, Bunbury Forum #1)

Dr [Y] telephoned later that day to say that he was coming to see our son. He was advised this was not possible because our son was asleep and we did not want him disturbed. Sometime before 4pm that same afternoon Dr [Y] together with an assistant and a police vehicle carrying three police officers arrived at our son's house and forced our son, who was ill and asleep at the time, to open his door. Needless to say our son was traumatised by the event. Fortunately my wife noticed the vehicles outside our son's house and we went to investigate. By this time the vehicles were moving off but we were able to speak to the police officers who were less than co-operative and the medical staff, who did not have the common decency to inform us of the visit, told us they were within their rights and that we had no reason to be upset. My contention is that Dr [Y] was not within his rights and by his actions he has caused a mentally ill patient additional needless trauma. My wife spent several hours with my son after the visit trying to calm him down...In my opinion the actions taken by Dr [Y] were completely inappropriate, unprofessional and unethical and have caused damage to a mentally ill patient and destroyed his faith in the Mental Health Service.

(Carer, Father, Western Australia, Submission #175).

There is an agreement between the police and the local mental health service. If patients are sectioned under the Mental Health Act the police are not allowed to transport more than 250 kilometres. Therefore the only option here is to take patients to Perth by the Royal Flying Doctor Service, the result being that the patient has to be extremely sedated. There is a need for them to be sedated to stop them from doing harm to themselves or others. I don't have a problem with that - but what I can't cope with is when I am asked to give a higher level of medication in order to transport this patient by air. Ethically I feel it is wrong to over sedate a patients in order to be transported by Royal Flying Doctor Service. This can lead to them being a vegetable for three or four days when they get to Graylands before they wake up. More than one I know of people having aspiration pneumonia and sometimes requiring intubation. I have to be able to live with myself having to do this. The potential is for a serious outcome of death - I don't want to take this risk. Why are we in a position of giving people enormous quantities of medication for the convenience of transport? Personally I have had people who were disturbed with whom I have had a good rapport and did not want to have to excessively sedate, but I had to do it. We're giving enormous quantities of psychotropic medication for this reason and whilst it has not happened yet there is a possibility I fear, of death. I know of patients who are also taking illicit drugs - we have no idea what is in their system. Why should I or other doctors - contractually obligated to give people this medication - be required to over sedate patients just for convenience of transport?

(GP, Western Australia, Geraldton Forum #53)

There are conflicting reports about whether or not the Royal Flying Doctor Service wants to transport mentally ill clients. Sometimes consumers have to wait another day to be sedated and possibly have a police escort to take them to Graylands. Sometimes they need armed escort.

(Anonymous, Western Australia, Geraldton Forum #52)

6.5.2.2 Lack of response to family concerns of danger

In an oral presentation at the forum in Geraldton, one father spoke of the failure of both mental health services and police to respond to calls for assistance for his son who was delusional and in crisis. Failure of mental health services to respond and provide treatment and support resulted in the community's right to safety being infringed (a homicide) and incarceration of a person with mental illness.

My son has been diagnosed as paranoid schizophrenic since 1996. My wife and I looked after him for two years. He was charged with wilful murder in November 2000. He is now in prison facing a 20 year prison sentence. In 1999 he received threatening letters ...He rang me from Maylands. I was unable to leave my wife. I was on call 24 hours a day because she was ill and my son was in Perth. He was delusional and needed help. Over four days I rang the crisis centre in Maylands Mental Health (PET) regularly and each time had to tell the full story - they wouldn't listen to me and wouldn't do anything. I rang the police nothing was done. They wouldn't do anything. After three and a half years in Graylands he is now better than he has ever been. He is now in Hakea prison. The help I got was none. For a dangerous situation there was no help available for me or my son.

(Carer, Father, Western Australia, Geraldton Forum #49)

6.5.2.3 Problems with use of security guards with inpatients

As a result of a shortage of secure beds, an unfortunate consequence has been the increased use of security guards in hospital settings. This has had the result of not only focussing the issue on containment rather than care, but also compromising the safety of both the consumer and security guards who are not trained for such situations:

One of the most disturbing practices for me is the use of security guards from a private security firm to facilitate the care of inpatients, due to lack of proper facilities and staffing levels in Bunbury. The hospital regularly employs guards to "special" patients who are considered at risk of either self-harm or absconding. They often use the guards to boost the staffing levels in the unit to try and make the environment safe. This can often mean an untrained person, usually male, following around a very ill or deeply disturbed person in the medical ward of the hospital as well as the psychiatric unit, or is sitting around in full uniform in the psychiatric unit. This has a couple of very major concerns. Firstly, the patient often self discloses to the security guard their personal history, which may often include a history of sexual abuse. Secondly, it also gives the patient, visitors and other patients, the impression that the person with the guard is "trouble", i.e. violent, bad, etc.

(Nurse, Western Australia, Submission #55)

I have witnessed young male security guards following around young female patients, watching them in their bedrooms. I have seen the situation escalate whereby a young male security guard, who had a history of depression, suicidal ideation in the past, have to try and restrain a female who was absconding from the Unit (as it is open and not a secure environment). He failed to restrain her, she absconded and placed herself on a tower in Bunbury threatening to jump off. The security guard was so distraught from the incident, feeling that he was responsible for anything that happened to her, that he began crying and had to be consoled by staff.

(Nurse, Western Australia, Submission #55)

6.5.2.4 Unsafe hospital and supported accommodation environments

Lack of adequate staffing and resources have also resulted in consumers feeling unsafe in a setting that provides little beyond a place to sleep and shower. Identification of safety risks by clinicians and release of Task Force Reports highlighting areas of clinical safety concerns appear not to have resulted in safety improvements:

I'm a patient in the hospital at the moment under an involuntary order and it was very difficult for me to get here to this forum today ...It's a place where you can get away from the world but there's not much else. The situation is terrible and I can't even have a shower in private. I'm scared and I have no privacy.

(Consumer, Western Australia, Bunbury Forum #17)

There are ethical, forensic, and practical problems. The nursing staff were put under an intolerable situation when there were people highly disturbed. There is no secure ward nor are there any plans for one, therefore there are no means to prevent people harming themselves.

(GP, Western Australia, Geraldton Forum #53)

Hostels like St. Bartholomew's House can no longer afford the risk of injury to staff and/or other residents from people who are not having adequate treatment and support from mental health services.

(St Bartholomew's House Inc, Western Australia, Submission #37)

A friend recently witnessed an extremely agitated young man who claimed he needed to see a doctor urgently at Avro Clinic and was told this was impossible and was turned away by the staff - an extremely dangerous situation!

(Carers, Parents, Western Australia, Submission #76)

Evidently, yet another report in October 2003 has confirmed the urgent need to address a range of issues pertaining to clinical safety on the inpatient psychiatric unit. It appears that someone has to sustain serious injury or to die before senior management (who hold budgetary control) can be encouraged to address the systemic problems that have been clearly evident for a long time. I can assure you that, as an humble clinician and with no ability to influence budgetary issues, I have found it extraordinarily frustrating to have been so powerless to influence clinical service delivery over the last few years of my employment with South West Area Health ....

(extract from a letter to the Chair of Mental Health Council of Australia)
(Clinician, Western Australia, Submission #24)

I am writing to you in order to express how appalled I am to hear that, eighteen months after the release of the Bunbury Health Task Force Report major problems with clinical safety at the Bunbury Hospital Psychiatric Inpatient Unit still continue ...I can only hope that now, with the release of yet another report, your Office and that of the State Wide Office of Mental Health will be able to insist upon change - before someone is seriously injured, killed or otherwise jeopardised ...

(extract from a letter to the Office of the Chief Psychiatrist)
(Clinician, Western Australia, Submission #24)

The absence of readily available psychiatric beds for emergency situations compromises clinical care and increase risk to the individual - and possibly to others.

(extract from a letter to the Director of Community Mental Health Programme)
(Clinician, Western Australia, Submission #24)

(i) -patients are being managed over long periods on emergency departments, the environment is unsafe clinically inappropriate, already struggling to meet demand and by no means secure. The re-sedation of patients is poor practice, traumatic and likely to lead to significant secondary trauma. It also gives a message that the patient is unwanted, by the ED [Emergency Department] or the Mental Health sector.

(Consumer Advocate, Western Australia, Submission #338)

(ii) - patients who require secure accommodation managed on open wards with a 1:1 or 2:1 nursing special. This is obviously poor practice, the nurse is at risk the patient is placed at risk as are other staff on the unit, and these are Mental Health patients, the messages given by inappropriate management are themselves highly relevant to the therapeutic outcome. The cost is phenomenal ...

(Consumer Advocate, Western Australia, Submission #338)

In Western Australia we have mental health services now that are provided in an unsafe and clinically unacceptable manner.

(Consumer Advocate, Western Australia, Submission #338)

6.5.2.5 Safety concerns for children with mental illness

A paucity of services for children and youth with mental illness was noted in many submissions. Not only does this jeopardise the safety of children and youth who are in need of care but another consequence is that if treatment is urgently needed children have been treated in inappropriate adult settings compromising their safety:

There's a 9-10 month waiting list for mentally ill children to get into care. Children as young as 13 years old are being put into Graylands Adult Units and they are exposed to adults who are dangerous.

(Consumer, Western Australia, West Perth Forum #41)

6.5.2.6 Lack of trust in MHS to ensure safety for consumers and the community

Submissions describe a system in Western Australia characterised by a lack of resources and services, high levels of stigma still present in the community and a failure of the MHS to provide the public with assurances that post-deinstitutionalisation, treatment and support is available and accessible to people with mental illness. As a result, families and the community report feeling unsafe and that their right to safety and the right of people with mental illness to feel safe have been compromised.

For quite some time now clinicians at the coal face have been struggling more and more in their attempts to provide safe, quality services to consumers and their families. Unfortunately, things seem to be getting worse rather than better. One of the major difficulties for those who provide services in the community is in accessing inpatient beds at times of emergency. There is no doubt that resultant delays expose seriously unwell patients, carers, staff and members of the community generally to increased risk of harm.

(extract from a letter to a Member of Legislative Assembly)

(Clinician, Western Australia, Submission #24)

It is all very well to expect the community to deal with mental health patients if they are medicated and stable, but what about those patients who are resistant to medication. How is this safe for the community?

(Anonymous, Western Australia, Submission #145)

It is, however, of enormous concern that the management of a challenging clinical situation in the community (the patient's home) was extended by about another hour simply on the basis of bed availability. It is undoubtedly the case that embarrassment and distress for the patient and family members would have been much more limited had an earlier departure for the hospital being possible. There would have been less concern and distress for other residents in the street some of whom were moving about to collect children from school. The time of 4 Police Officers and 2 Police vehicles was extended unnecessarily, by a further hour. Equally, resources of the Mirrabooka Clinic and a local general practice were also tied up for longer than was necessary on a clinical basis ... This clinical situation demonstrates, once again, the additional cost to the community as a whole that results from an insufficiency of beds for emergency admissions under the Mental Health Act. There is not only the emotional and psychological cost to the patient, family and neighbourhood community members but also the actual cost in monetary terms to the Police service, community clinic and general practice.

(extract from a letter to the Clinical Director of the North Metro Health Service)
(Clinician, Western Australia, Submission #24)

6.5.2.7 Occupational health and safety issues

Scarcity of resources, diminishing funding and an increase in demand for those providing services has also resulted in unsafe work practices, jeopardising the safety of both consumers and staff:

A number of workplace incidents occurred at St Bartholomew's House, which resulted in a $350,000 payout for one staff member and another claim still pending at the time of writing this submission. WorkSafe attended and put a number of work improvement orders on the property. The outcome of those orders and the increased workers compensation claims only exacerbated the viability issues already being experienced by the SAAP [Supported Accommodation and Assistance] program.

(St Bartholomew's House Inc, Western Australia, Submission #37)

...despite clinician concerns, the SWAH [South West Area Health] did nothing to act on the deteriorating situation at the Molly St clinic. It was, I understand, only because the landlord chose to terminate the lease that the SWAH actually started to act. Lamentable given that ...actual harm to ...clients [was identified] by the situation as it existed in the Molloy St clinic.

(Anonymous, Western Australia, Submission #1)

6.5.3 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 participation by consumers and carers in planning, implementation and evaluation processes by the MHS.

We have given up trying because there is no where to go, we have run out of steam.

(Consumer advocate, Western Australia, Submission #35)

6.5.3.1 Participation by consumers and carers

Significant concerns were expressed via submissions and at forums about the state consumer and carer participation in Western Australia. Some reports indicated the belief that the WA Government and health administrators made a decision to diminish the involvement of consumers and carers in the planning, implementation and evaluation of the MHS. There were also claims of not being consulted prior to critical service delivery decisions being made and the de-funding of programs which trained and supported consumers and carers to participate in such activities:

The Health Consumers' Council operated a Mental Health Consumer Advocacy Program for six years until this was de-funded in late 2003. This program supported consumer participation in service decision-making, trained consumers as public speakers on service standards and provided a Participation Payment scheme to assist consumer participation. The most promising feature of this program was the employment of mental health consumers as advocates for service reform. Consumers worked on a part-time basis in a team supporting a wide network of peers involved in service reform work. The cost to the state of this program was in the order of $130K per year - 4 workers, 200 consumer reps, 100 committees. The loss of this program was catastrophic for the emerging mental health consumer movement. Almost all progress against the National Mental Health Plan in respect to consumer participation in mental health services has stopped in Western Australia.

(Health Consumers' Council WA, Western Australia, Submission #29)

Mental health consumers are the great hope for the reform of mental health services in this state and no double elsewhere. ... [U]ntil the users of mental health services are brought into the centre of the service delivery culture, there will be no change for the better. Consumer participation in meaningful and robust ways, will be the singlemost important accountability mechanism that will improve the safety and quality of mental health services in this state ...

(Health Consumers' Council WA, Western Australia, Submission #29)

Only recently in July, Carers at a Carer Advocacy & Issues Forum in Bunbury met and expressed their frustration regarding the sudden closure of mental health services in their community. Specific concerns regarding the closure of services include: ...The complete lack of consultation with carers, consumers and health professionals regarding the closure.

(Carers WA, Western Australia, Submission #277)

Can you please tell me what specifically Mirrabooka MHS is doing to enable carers to "shape reform" and "to meaningfully participate at all levels"?

(Carer, Husband, Western Australia, Submission #146)

There are many consumer advocates employed here in WA but the attitude is one of extreme paternalism by the Office for Mental Health - when consumer advocates speak up and their position is in any way critical of the Government or the system, they are classed as being unwell.

(Consumer advocate, Western Australia, West Perth Forum #28)

...our deep concern over the ever dwindling services available to people and families, living with mental illness. This is accompanied by an apparent lack of responses to efforts to raise these concerns. The points of concern are:

•  Closure of clinic patient access, and cancellation of appointments and therapy program.

•  Lack of information

•  Lack of consultation

•  Lack of apparent plan / direction

•  Suspension of living skills program

•  Discontinuation of consumer / carer reference group

•  Limited therapy program at the inpatient unit, including outpatients' access

•  Repeated failure to employ staff to fill vacated positions

•  Southwest 24 being "one point of access"

It would appear that these decisions have been enacted with very little consideration being given to the consequential impact. It is without question that consumers and their families are experiencing a huge increase in their anxiety levels and a similarly huge decrease in their confidence in South West Area Health Services.

(Anonymous, Western Australia , Submission #22)

[Supporting mothers with mental illness] Recommendations: Increase the use of consumer groups including adult children to train mental health clinicians on the effects of parental mental illness

(Health Consumers' Council WA, Western Australia, Submission #29)

Mental health consumers are the great hope for the reform of mental health services in this state and no double elsewhere ... [U]ntil the users of mental health services are brought into the centre of the service delivery culture, there will be no change for the better. Consumer participation in meaningful and robust ways, will be the singlemost important accountability mechanism that will improve the safety and quality of mental health services in this state ...

(Health Consumers' Council WA, Western Australia, Submission #29)

The Health Consumers' Council operated a Mental Health Consumer Advocacy Program for six years until this was de-funded in late 2003. This program supported consumer participation in service decision-making, trained consumers as public speakers on service standards and provided a Participation Payment scheme to assist consumer participation. The most promising feature of this program was the employment of mental health consumers as advocates for service reform. Consumers worked on a part-time basis in a team supporting a wide network of peers involved in service reform work. The cost to the state of this program was in the order of $130K per year - 4 workers, 200 consumer reps, 100 committees. The loss of this program was catastrophic for the emerging mental health consumer movement. Almost all progress against the National Mental Health Plan in respect to consumer participation in mental health services has stopped in Western Australia."

(Health Consumers' Council WA, Western Australia, Submission #29)

A submission by a Professor of Mental Health Nursing, detailing how positive change was recently brought about in a psychiatric hospital, emphasised that the key to improving the protection of the rights of people with mental illness was the involvement of consumers:

By empowering patients, consumer representatives and the clinical nurses, major changes have been brought about in the NPDU [Nursing Practice Development Unit]. Most of the alterations reflected improvements in human rights that most people in the wider community would have assumed were already been in place.

(Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

The prime movers in initiating and maintaining the changes have been a minority of nursing staff on the ward and the consumer representatives. They effected major improvements on the ward despite a social and organisational environment that was at times sceptical and at other times obstructive to their efforts. It was mainly through the drive of these committed people that the changes mentioned in this report were possible.

(Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

It can be seen that the introduction of a 'bottom up' system of management not only impacted on the quality of living conditions and the environment of the ward but it also positively affected the perceptions and feelings of patients and nurses about the services offered. There was an increase in patients' satisfaction in the NPDU. There was also a reduction in burnout scores and a drop in the seclusion rates in the NPDU despite the increase and the maintenance of the high levels of bed occupancy within the ward during the evaluation period.

(Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

6.5.4 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:

  • discrimination in the workplace and the need to educate employers;
  • lack of community acceptance and support; and
  • the need for community education.

6.5.4.1 Discrimination in the workplace - need to educate employers

Employment and a supportive workplace are seen as key factors in preventing the rapid deterioration of mental illness and essential in the process of rehabilitation and reintegration into society after a period of illness. However, acceptance and understanding of mental illness seem to be lacking in the workplace and, according to submissions received, discrimination and high levels of stigma are still prevalent. The need for employer education and additional anti-discrimination campaigns were expressed by consumers, carers and government employees:

I am a nurse but I have been told that I will never get a job in this area because of my previous mental health condition.

(Consumer, Nurse, Western Australia, Bunbury Forum #2)

Basically we have to deal with the stigma and discrimination that is entrenched. For example, take a police officer with a mental health problem - a possibility with all government agencies. If a police officer has a broken leg it is acceptable, but if they need medication or time off for mental health reasons they are discriminated against. There is an entrenched stigma and no one is looking after them. It's a culture - police officers are too proud and don't feel free to talk about it. There is a need for publicity saying that you can't discriminate against it ...

(Police Officer, Western Australia, Geraldton Forum #90)

I have three family members with mental health problems. Personal experiences have been traumatic. There is a need for more facilities and need more education of employers. Most employers feel that if a person doesn't turn up for work, they won't have a job. Mental health clients may have difficulty sleeping and therefore are not fit to turn up for work the next day. There are difficulties with the control of medications. There is a need for more emphasis on rehabilitation and part-time work.

(Carer, Western Australia, Geraldton Forum #50)

6.5.4.2 Lack of community acceptance and support

Carers and community members spoke of the continued discrimination and isolation experienced by people with mental illness and their families. Of particular importance was a claim made by one carer that discriminatory practices are also being perpetuated by health providers and the government, indicating that community education programs need to encompass the community, the government and workplace training. Increasing community understanding of mental illness, acceptance of people with mental illness and information about how to support people with mental illness and their families and carers is critical to destigmatise mental illness and realise the social, economic and political participation rights of people with mental illness. The ongoing failure of governments to achieve this has devastating consequences:

I can understand how there are so many suicides in our community. Any hope for a normal life is minimal. Not only is the welfare of these people ignored there is positive discrimination against any progress they might want to make. More understanding and education is needed. The last government (and only) education campaign fell far below the mark required. Mental health sufferers need long term care and understanding. Not only by the general population but also (and more so) by the health industry and government.

(Carer, Western Australia, Submission #163)

I also want to talk about an incident that happened recently in my street. My neighbour took a turn 7 months ago and as a community member I was frightened by what was happening. I was seeing a situation worsen. I tried to support the mum by going in and talking with her. She told me that the neighbours would just have to put up with it. I think if the system was working then that person would have had some community support.

(Anonymous, Western Australia, Bunbury Forum #18)

...[my] son who was diagnosed with schizophrenia when he was 18 ... [X] has been unable to hold down a job and has lost his friends along the way ... His father will not allow him back home... [X] is a young man who is very lonely, spending so much time on his own - which does not help his condition. It is so sad so sad to see. He was a champion runner, but that has all gone now.

(Carer, Mother, Western Australia, Submission #99)

6.5.4.3 Need for community education

Without community education, not only will community acceptance and understanding not be forthcoming, but fears based on myths, stereotypes and inaccurate information will continue. This will further perpetuate stigma and discrimination and support an unwarranted call for seclusion and restraint and the curtailment of rights of people with mental illness:

It is all very well to expect the community to deal with mental health patients if they are medicated and stable, but what about those patients who are resistant to medication. How is this safe for the community?

(Anonymous, Western Australia, Submission #145)

In Western Australia mental health problems are shrouded in ignorance. Few people ever think about the mental health needs of our communities and even less people think about the needs of mothers with mental illness and their children. The cost to our community is only counted in fiscal terms for the Health Department ... Systemic prevention education will complement systemic cross sector collaboration and build a recognition and understanding of the difficulties encountered by mothers with mental illness and their children. Recommendations: Develop comprehensive and sustained education programs to implement a systemic approach to mental health.

(Health Consumers' Council WA, Western Australia, Submission #29)

[Supporting mothers with mental illness] Recommendations: develop policies to change the belief that a problem within the family is the family's problem to recognising that a problem within a family is also a problem for the society.

(Health Consumers' Council WA, Western Australia, Submission #29)

6.5.5 STANDARD 5: PRIVACY AND CONFIDENTIALITY

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

Under this Standard, submissions and presentations indicate concerns about:

  • lack of privacy and control over personal space;
  • the Privacy Act and policies related to confidentiality; and
  • the MHS denying consumers their right to have others involved in their care.

6.5.5.1 Lack of privacy and control over personal space

Lack of privacy and personal space available at mental health services is still of major concern to consumers and carers:

Many people fear that ultimately Graylands Hospital will be closed down, as was Heathcote Hospital. It should always be born in mind that to replace beds in a facility like Graylands Hospital with its peaceful surrounds with extra beds in a general hospital like Royal Perth or SCGH [Sir Charles Gairdner Hospital] with their locked wards and lack of personal space is absolutely a huge step backward!

(Carers, Parents, Western Australia, Submission #76)

The patients have lost their group room, which now houses community staff, desks and computers. The whole APU [Acute Psychiatric Unit] is an overcrowded situation with the community staff moving into the small premises.

(Nurse, Western Australia, Submission #55)

Issues of Bunbury Mental Health Services:

•  The interim arrangements for the community staff currently is that offices within the therapy areas of the inpatient unit are being utilised. These staff do not have facilities that are deemed to be suitable for seeing patients. Plans are now in process for renovations to take place to extend the offices and make them suitable for patient contact. It is said that these arrangements will be in place for 8 to 12 months. The decisions for these arrangements have again been behind closed doors by unidentified managers. The implications for consumers are many:

•  The inappropriateness of having appointments with community staff within the inpatient unit of the hospital, is not an acceptable to many people
•  This creates a huge impost on the workings of the inpatient unit, which is already operating under duress. It directly limits the opportunity for therapy and comfort of inpatients.
•  It again fails to recognise the need to involve consumer in decisions in which the consequences are borne by the consumer group.

(Advocate, Western Australia , Submission #2)

6.5.5.2 Privacy Act and policies related to confidentiality

Both clinicians and carers expressed concerns that a misunderstanding of the Privacy Act and policies and procedures to protect the confidentiality and privacy of consumers is hampering communication between consumers, carers and clinicians in the provision of treatment. Furthermore, these concerns would indicate that these policies and procedures are not being made available to consumers and carers in an understandable language and format (Standard 5.2) and that the MHS is not encouraging and providing opportunities for consumers to involve others in their care (Standard 5.3):

Carers continue to report that they feel there is minimal recognition of them by mental health services and minimal efforts to consider their views and/or involve them. Whilst Carers respect the need for confidentiality the lack of possible involvement of carers is a significant barrier to carers in providing care and support for their family members/friends with mental illness.

(Carers WA, Western Australia, Submission #277)

I would also like to say that there is a lack of communication because of the Privacy Act.

(GP, Western Australia, Geraldton Forum #62)

She was over 18, depressed and when I informed her doctors of paternal depression they didn't want to know. Surely if a person is in crisis doctors should listen to family members who may be able to throw some light on a situation. The Privacy Act has gone too far.

(Carer, Mother, Western Australia, Submission #103)

6.5.5.3 MHS denying consumers their right to have others involved in their care

Despite Standard 5.3 stating that the 'MHS encourages, and provides opportunities for, the consumer to involve others in their care' submissions were received indicating that some services actively discourage the involvement of others (carers and other mental health workers) in treatment and care plans. This denial, especially when involvement was specifically requested by the consumer, angered both consumers and carers alike. The exclusion of carers was seen to be detrimental to the planning and delivery of treatment and support:

Some months ago I had a client ask me to accompany him to see his psychiatrist for a 2 pm appointment. The client requested I went in with him, I agreed. The mental health person said that they wanted a few minutes with the client by himself first. I waited the hour and when the gentlemen returned I was just not acknowledged or communicated with. At least I would have liked some acknowledgement and some courtesy.

(Clinician, Western Australia, Geraldton Forum #71)

I made an appointment to see the psychiatrist outside of school hours so that my wife could to attend too. I was told you are the patient and they did not approve of my wife being at the appointment. I need the support of my wife as I always have to discuss the appointment with her afterwards as I am unable to remember it all and it helps me to understand things better. I was disturbed by the attitude of this person. I was asked do you want the appointment or don't you? I said No.

(Consumer, Western Australia, Geraldton Forum #72)

6.5.6 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:

  • no prevention and early intervention is happening due to the lack of access to services; and
  • lack of services for youth, no early intervention or mental health promotion possible.

6.5.6.1 No prevention and early intervention is happening due to lack of access to services

Concern was expressed about the inability of consumers and carers to access services at the earliest possible moment or to have services respond appropriately when contact was made. Reports were received of occasions when serious consequences occurred such as escalating illness, suicide, or incarceration:

I would like to comment on the fact that people with a mental illness are being arrested because often it's the only way they can get any help. They have a right to get care, not be arrested. We've got to get access to early intervention programs but it doesn't happen - now my brother is in the court system, not because he's bad but because he's got a mental illness.

(Carer, Sister, Western Australia, Bunbury Forum #24)

My eldest child gassed himself in his car. After that when we really needed support there was hardly anything for us. It was the lack of support that led to my husband walking out - our family broke up because we had nowhere to turn for help. Then my 12 year old son tried to hang himself on the washing line. I got him down and we got treatment from a private psychologist but he later hung himself in his flat. I have lobbied through Lifeline and Parliament and I have got nowhere - I am not a judgmental person but I find [the Minister for Health] is aloof and doesn't care. We need to educate our young people about mental illness and about how to ask for help. Where's the money to educate our young people to ask for help?

(Carer, Mother, Western Australia, West Perth Forum #35)

National Mental Health Plan 2003-2008 ...Page 20 - "Outcome 9: Improved access to early intervention services."...the reality is 'the system' does nothing unless the consumer is either psychotic, suicidal, or in some other emergency.

(Carer Advocate, Western Australia, Submission #339)

Consumer relapse knowledge ignored. Consumers who feel themselves to be becoming unwell have little or no access to assistance from their treating team. It is not uncommon to contact a clinic on behalf of a consumer who feels the need for immediate intervention and be told that the referral will be placed on a list to be discussed at an 'intake' meeting at a later date ...It is the experience of mental health consumers with early signs of relapse or episodes of need that the inability of services to respond to their needs pushes them towards crisis, disruption of their life and greater need to call on those same mental health services.

(Health Consumers' Council WA, Western Australia, Submission #29)

6.5.6.2 Lack of services for youth - no early intervention or mental health promotion possible

Numerous submissions were received that commented on the lack of mental health services for youth. This was seen as a significant failure by the mental heath service in their ability to identify and respond as early as possible to this vulnerable group with mental health problems and prevent deterioration and negative life consequences:

Youth mental heath services ...At the moment there's no access to services at all - previously there was a 6-months waiting list - so the notion of early intervention or prevention doesn't exist for this community.

(School counsellor, Western Australia, Bunbury Forum #8)

I have noted the following issues with the Mental Health Services in both Carnarvon and Geraldton; The Child and Adolescent Mental Health service in both Geraldton and Carnarvon has not been running for substantial periods of time over the past three years. This has left many children and adolescents at high risk of suicide. In Carnarvon a number of Aboriginal adolescents have committed suicide.

(Clinician, Western Australia, Submission #333)

[I]n Meekatharra the CAMHS [Child and Adolescent Mental Health Service] worker who visited once every two months was always booked out with appointments. Therefore, it would appear that the need indicated that the amount of times she visited should have been increased. Instead these visits are no longer taking place.

(Clinician, Western Australia, Submission #333)

"To invest in the effective treatment of young people where mental health issues are a concern is of paramount importance. It can and does change the entire trajectory of an illness over a lifetime as so many studies have indicated. I'm sure this needs no debate." (Consumer contribution to Mental Health Coalition Council On-line forum).

(Consumer Advocate, Western Australia, Submission #338)

6.5.7 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:

  • staff imposing their own religious and cultural attitudes on consumers; and
  • the cultural background of consumers and carers is not being respected and considered in the delivery of treatment and support.

6.5.7.1 Staff imposing their own religious and cultural attitudes on consumers

Cultural awareness includes awareness by staff of their own cultural and religious values and an understanding that it is not appropriate to impose their values and beliefs on consumers. As the following statement shows, this is not always the case:

[I] attended the hospital with a friend who had attempted suicide. This was after hours. When I took her to the A and E she was initially checked over for any physical effects of the overdose she had taken. She also reported that she had been abused as a child. The consulting doctor then talked to her at length about religion indicating to her that people who commit suicide "go to hell". This greatly upset my friend who was already very upset. She said later it made her feel guilty about what she had done ...An understanding and non-judgemental attitude would also have helped.

(Clinician, Western Australia, Submission #333)

6.5.7.2 Cultural background needs to be respected and considered in the delivery of treatment and support

Concern was expressed by carers that the cultural background of consumers and carers needs to be understood and respected more. In a special focus group with carers from culturally diverse backgrounds, this was identified as an important issue to be addressed so that treatment and support was sensitive to social and cultural beliefs, values and cultural practices of the consumers and their carers (Standard 7.3). The following comment indicates that staff may need to receive cross cultural training (Standard 7.5) or have more specific knowledge of social and cultural groups of communities represented in their area (Standard 7.1):

The focus group was held with carers from culturally and linguistically diverse backgrounds. Again the findings from the focus group were consistent with the written surveys with the following addition. To the question "What three things would you change about mental health services?" carers would like to receive more respect for their different cultural backgrounds and that mental health service staff understood their particular cultural and family background better so that carers' own situations would be respected. (McKeague B, 2003. Worried, Tired & Alone - A report of Mental Health Carers' Issues in WA. Briefing Paper)

(Carers WA, Western Australia, Submission #277)

6.5.8 STANDARD 8: INTEGRATION

6.5.8.1 Service integration

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

Under this Standard, submissions and presentations indicate concerns about:

  • more staff and resources required for integrated service to respond effectively to crises;
  • lack of cooperation within MHS - poor attitudes towards patients and providers from rural and regional areas;
  • lack of any youth mental health services; and
  • MHS not providing continuity of care for consumers.
6.5.8.1.1 More staff and resources required for integrated service to respond effectively to crises

Concern was expressed that an insufficient number of staff and lack of resources were factors which were seen to inhibit the provision of integrated and continuous care to consumers in crisis (Standard 8.1).

I have a friend who had a mental breakdown ...I rang the mental health team and they couldn't see her for 5 days, there was no appointment for three to four weeks. The GP tried to cope. Good clinicians took her details but three, four weeks later she was asked the same questions again. There is a lack of staff - the team in community and lack of coordinated services. For example, home help etc.

(Friend, Western Australia, Geraldton Forum #65)

...my wife was suicidal and the psychiatric nurse on-call ...refused to come and see her. She ended up in hospital that night, spending the night in [Z] Emergency Department because there were no beds ...my wife was suicidal again ...I immediately wrote a letter to Dr [psychiatrist] on her behalf, expressing my grave concern at her current mental health status, her risk for suicide, and her need for urgent treatment and assessment. My letter was not even acknowledged! [Z] MHS couldn't be bothered seeing my wife until the following week. I was forced to call PET [Psychiatric Emergency Team] in order to get my wife assessed. I find this totally unacceptable. (author's emphasis)

(Carer, Husband, Western Australia, Submission #146)

It is intended to fill the position with a person qualified in mental health. But one person doesn't make a team.

(Anonymous, Western Australia, Geraldton Forum #105)

GRAMS [Geraldton Regional Aboriginal Medical Service] see the patient straight away will see the client anywhere - at home or the clinic night or day. The psychiatric nurse is currently on leave but there is a query regarding him coming back. We may loose his expert skills, compassion and local knowledge. Retention is a big problem - building relationships. If we loose them we have a big problem supporting the workers.

(Anonymous, Western Australia, Geraldton Forum #93)
6.5.8.1.2 Lack of cooperation within MHS - poor attitudes towards rural and regional patients and providers

Given the vast geographical area of Western Australia and the rationalisation of services and resources to principally metropolitan areas, poor staff attitudes, which lower the standard of care delivered to consumers from rural and regional areas, is of serious concern for many reasons. Consumers from rural and regional areas have no alternative avenues of care to pursue; metropolitan services are aware in their service plans that consumers from rural and regional areas will access their services; practices of early discharge and lack of follow up plans for consumers who cannot readily return or rely on other support services are unsafe for the consumer. For consumers in rural and regional areas continuity of care is problematical due to the scarcity of services outside metropolitan areas:

Of great concern is the attitude of Perth Metro area hospitals regarding the patients from the South West. Often the statements are we have "one of yours", our hospital is full of "your" patients and I was even told by a senior clinician that our patients were using up the beds in Perth funded by her tax money! There is a perception in the community and by the community mental health team that patients from the South West are discharged prematurely and without follow-up being arranged.

(Clinician, Western Australia, Submission #55)
6.5.8.1.3 Lack of youth mental health services

The lack of mental health services for youth makes the realisation of Standard 8.1.5: 'The MHS has documented policies and procedures which are used to promote continuity of care across programs, sites, other services and lifespan' problematic.

The lack of youth mental health services means that services for youth are not integrated, coordinated and balanced, and from evidence presented, it would appear that services are either non-existent or inappropriate for this age group:

Youth mental health services are disconnected and often staffed by people with limited or no experience in working with these client groups. At the moment there's no access to services at all ...We can't get staff with the right skills to this area. The situation is very poor and we rarely receive information about what's happening with services.

(School counsellor, Western Australia, Bunbury Forum #8)

I've been on a few committees and it's not the service providers who are the problems; they are on our side. It's the politicians and our government that are negligent - can the Human Rights and Equal Opportunity Commission help us? There's a 9-10 month waiting list for mentally ill children to get into care.

(Consumer, Western Australia, West Perth Forum #41)

The psychiatrist that was here before was great with feedback to other services and families - now the situation is hopeless. There are 2 of us (school counsellors) covering 8,000 people in this area.

(School counsellor, Western Australia, Bunbury Forum #8)

When a young person visits the mental health service or GP and has a bad experience they loose confidence with the organisation as they feel let down and are reluctant to revisit and therefore have no where else to go. It becomes a problem.

(Anonymous, Western Australia, Geraldton Forum #93)
6.5.8.1.4 MHS not providing continuity of care for consumers

Concern was expressed about the ability of the MHS to provide a balanced mix of services to ensure continuity of care for consumers (Standard 8.1.5). Problems ranged from lack of services to deliver treatment and support after being discharged from hospital, lack of coordinated services in the community to provide sufficient support for consumers and their children to live independently in the community, long wait lists for services and a failure of the MHS to integrate with NGO service providers:

There is no continuity of care. If you can't get better in a short period of time - tough. I needed to see someone sooner.

(Consumer, Western Australia, Geraldton Forum #66A)

My son is 19 and he has chronic schizophrenia and a drug abuse problem. He's been in the locked ward at Graylands for quite a while and I'm glad he's been locked up for that long because he can't cope outside the hospital. He lives with me and I worry about what will happen to him if he is released. He can't be accommodated anywhere and this is a human rights issue. There's unreasonable pressure on the family to provide care for really sick people like my son.

(Carer, mother, Western Australia, West Perth Forum #31)

I have schizophrenia and over the past 6 weeks I have had problems, as I have been given a new medication which has made it difficult for me to do my housework and to look after my 6 yr old daughter. My psychiatrist comes from Perth fortnightly and I have to make an appointment a month ahead. I have been unable to get help from CWMH [Central West Mental Health] to enable me to look after my daughter and do my housework; I have taken myself off the medication for two days at a time. My caseworker has not been available and no one else has been available to make a decision for me.

(Consumer, Western Australia, Geraldton Forum #41)

I also suffer from depression. The changes 9 months ago to the structure of the care of hospitalised patients have reduced the ability for GPs to look after their own patients as they did in the past. GPs no longer work with their patients when they are in hospital.

(GP, Western Australia, Geraldton Forum #53)

There were a number of GP's in Bunbury who wanted to be involved with the mental health unit but only if there was adequate support. We don't have that support anymore.

(GP, Western Australia, Bunbury Forum #19)

My daughter was waiting for treatment and she had to wait 7 months to see a psychologist. It got to the point where she started using drugs to help her symptoms. Basically it got to the point where the psychologists would say they wouldn't treat her because of her drug use but the drug and alcohol service wouldn't treat her because she was severely depressed!

(Consumer and Carer, Western Australia, West Perth Forum #34)

Issues of Bunbury Mental Health Services:
The current interim arrangements provide limited opportunity for appointments with psychiatrists, psychologists or social workers. This is having an impact on individuals who previously were seeing one of these clinicians regularly. In some case this has resulted in hospitalisation, pressure on GPs and other support services.
(Advocate, Western Australia, Submission #2)

We were very satisfied with the therapeutic relationship he had developed with the doctors at RPH [Royal Perth Hospital] over that period. However, when ever he suffered a psychotic episode or required any other external support, RPH were unable to provide this as our son resides outside their catchment area, the PET team were unwilling to become involved and they required us to call the police to render assistance. We and Dr [Y] have attempted to have this rectified by enjoining with Armadale clinic, they in turn refused to attend or become involved unless he became one of their patients. Finally in desperation his files were transferred to Armadale and we set about trying to arrange an appointment. Whilst we waited for the appointment (some three months later) he experienced several more episodes which were reported to the Mead clinic who in turn were unable to assist because he had not yet seen one of their doctors. The classic catch 22. Finally the day for the appointment dawned but when we arrived, we were told it had been cancelled and rescheduled for the following week.

(Carer, Mother, Western Australia, Submission #13)

I do not refer to Mental Health Services because of past experiences, particularly as they will not see people who have a drug problem. I use GRAMS [Geraldton Regional Aboriginal Medical Service] where possible.

(Anonymous, Western Australia, Geraldton Forum #94)

If the client is using drugs then they are not a mental health patient there is a gap in this situation.

(Anonymous, Western Australia, Geraldton Forum #94)

Mental Health Services' response there has been poor. Appointments are 2 weeks into the future - On one occasion a client went there and was told he was fine. Therefore I sent him to GRAMS [Geraldton Regional Aboriginal Medical Service]. They see everyone there, not just Aboriginal people.

(Anonymous, Western Australia, Geraldton Forum #94)

Concern was also expressed that the MHS is not integrated with NGO service providers to provide continuity of care:

At the Department of Community Development, for many years field workers have commented that there are no links or feedback with mental health services. When they take people along with personality disorders and they say no they don't deal with them as they don't fit and we have had problems in that area, they are sent back to our workers. Sometimes we do have a working relationship but I do have to say that there is not a good networking relationship with the mental health service. We have a counselling service where we see quite a number of mental health people who do not have access to the mental health service. Also our NGO counselling services have a number of people with mental health problems and therefore their services are overloaded. The mental health gatekeepers keep them away. We have family counsellors and a lot of our other services and some NGOs funded by DCD.

(Department of Community Development worker, Western Australia, Geraldton Forum #85)

...organisation through its contractual agreement with the Health Department of WA is directed to only take referrals from the SMHS [South West Mental Health Service]. However if clients are to be referred to their GPs for treatment then they will have no means of access to the Community Support Services in their area. This loop hole in the referral process can for many mean they will have no daily support networks and will be totally reliant on GP visits or repeat calls to South West 24 Services for any contacts or support. Again this tends to demonstrate the lack of communication or recognition of the NGO services providers.

(NGO Service Provider, Western Australia, Submission #45)

The MHS doesn't help - the only ones who help are Baptist Care and GPs are left to pick up the pieces. Government does nothing.

(Former consumer, Western Australia, Geraldton Forum #60)

As the following examples show, for some people, their experiences of accessing care or providing other services were extremely positive. Unfortunately, the relating of positive experiences was not a common phenomenon but the reviewers acknowledge it is more likely that people who have had negative experiences come forward to give evidence.

I had a very positive experience with the Molloy Street Clinic. I got the right sort of care when I needed it. My child was born recently and I had anxiety but because I got care I'm okay. My concern is that I'm a really good example of a person who might not be here in the future now that the clinic is closed.

(Consumer, Mother, Western Australia, Bunbury Forum #21))

I would like to speak in defence of the mental health service and in the region. Carelink is a federally funded government service. In defence of mental health staff they do contact me to get help they are quite happy to call me to access services - I get a lot of phone calls from mental health services for people who have been unable to contact my service.

(Anonymous, Western Australia, Geraldton Forum #88)

6.5.8.2 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, submissions and presentations indicate concerns about:

  • problems with integrated and continuous care when consumers are admitted to hospital for physical illnesses; and
  • difficulties encountered by consumers in accessing General Practice.
6.5.8.2.1 Problems with integrated and continuous care when consumers are admitted to hospital for physical illnesses

One consumer expressed concern that she was unable to continue seeing her caseworker while she was in hospital for a physical condition. This suggests that links had not been established, that the MHS was not part of the general heath care system or that polices and procedures were not adhered to:

I've recently been to hospital for a physical condition. I asked to see my caseworker whilst in hospital. I was informed that I could only talk to my case manager on the phone or she could visit as a friend not as a professional. I would like to know why?

(Consumer, Western Australia, Geraldton Forum #2)
6.5.8.2.2 Consumers and problems with accessing General Practice

One general practitioner noted as a concern that, from his experiences, people with mental illness have difficulty accessing general practice. This has implications for consumers in their ability to seek treatment for either mental or physical illnesses:

I suppose the thing to say is that people have difficulty accessing general practice particularly if they have a mental illness.

(GP, Western Australia, Bunbury Forum #19)

6.5.8.3 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:

  • the need for a whole of government approach;
  • lack of support from Centrelink;
  • lack of support for families;
  • police; and
  • the lack of housing and accommodation options.
6.5.8.3.1 Whole-of-government approach needed to improve outcomes for people with mental illness and their families and carers

Overall, many submissions indicated a lack of integrated service delivery or of a whole-of-government approach to solve the complex support needs required for people with mental illness and their families and carers to live in the community in a dignified manner. These problems were reported with welfare, criminal justice, community service, legal, housing and disability services. Many submissions identified that a broader governmental, societal and community approach is required:

Come and walk in our shoes for a day - we're damned no matter how hard we work we can't win. There's a lack of resources but also a societal problem. It's a whole of government approach that's required.

(Clinician, Western Australia, West Perth Forum #40)

I am a solicitor recently come to Geraldton and I find there is a poor nexus with mental health services. Local mental health services will not supply letters to the legal system therefore people are being charged instead of treated. There was one instance where a person was heard by 2 JPs [Justice of the Peace] who could not order an assessment, this was referred to a Magistrate in Carnarvon. I am not aware of any assessments being brought on in Geraldton. I am concerned because it then goes through to what? This is a concern to me. There needs to be improvements in communications.

(Solicitor, Western Australia, Geraldton Forum #57)

In 2001 I was caring for a foster child who had a mental and a physical disability. When I took him in for care I was told he didn't have a mental illness and he was discharged by the hospital on the Friday but was then admitted to Graylands and I was told he has schizophrenia.

(Friend, Western Australia, Bunbury Forum #3)

[Supporting mothers with mental illness] Recommendations: Use the education system as the primary system for referral forums to develop greater cooperation between education, child development, child protection, family support and child and adolescent mental health systems. All systems use the same tax dollar.

(Health Consumers' Council WA, Western Australia, Submission #29)

Lack of integration and coordination with Disability Services was also reported:

My brother is both Bipolar and has an intellectual disability. I believe his convictions are a direct result of the lack of available services to him whilst he tries to live independently in the community. Up until now we have always had to jump hurdles in order that the Mental Health Services and Disability Services work together as a team

(Carer, Sister, Western Australia, Submission #101)
6.5.8.3.2 Lack of support from Centrelink

With declining access to mental health services, supported accommodation and the implementation of early intervention strategies, the burden on families and carers to provide 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:

My husband has drug resistant schizophrenia. My son is deeply affected by my husband's illness but we get no support from Centrelink for the effect on our kids. To give you an idea how bad Centrelink treats us I got a computer generated letter indicating that our pension had been cut off.

(Carer, Wife and mother, Western Australia, West Perth Forum #26)
6.5.8.3.3 Lack of support for families

When people with mental illness are living in the community, many other supports may be required beyond direct treatment and support for their mental illness as well as assistance with rehabilitation and integration into the community. These additional supports may be financial as discussed above, or more frequently, are required in the form of assistance for the family as a unit, e.g. care for children if a parent with mental illness requires hospitalisation, support for families after the suicide of a family member with mental illness, or community support services for the family to cope on a day to day basis. The following quotes highlight the support services required, their lack of availability and the impact on families:

I am an NGO provider. Our surplus of funding from last year was taken from us by the Government without notice. The Government just doesn't think about the implications of taking away funding from NGOs. We already have long waiting lists and taking away funding makes them even longer. One of the young consumers who was on one of our waiting lists for four months was also caring for her Mum - she killed herself because she felt she couldn't cope looking after her mum anymore without some support. Waiting lists for support from us have gone up from three weeks to four months.

(Service Provider, Western Australia, West Perth Forum #29)

There is no available respite for families/carers of those people with mental health issues. However, for a carer of someone with an intellectual disability resources are available for respite. This raises another concern which is for that of the mental and physical health of the carer. (I have seen the health of carers and their families - including young children - deteriorate as they struggle to cope with their loved one).

(Anonymous, Western Australia, Submission #145)

Despite the fact that in Busselton there is LAMP (a support for carers and some limited activities are organised for mental health patients) and Pathways (a four bedroom house for limited respite which covers the whole of the South West) in Bunbury, if a patient is considered disruptive then he/she is not referred to these places and the burden continues to rest with the family with no respite at all.

(Anonymous, Western Australia, Submission #145)

The profound impact on the families of the mentally ill needs to be given due consideration and care.

(Carer, Sister, Western Australia, Submission #101)

Carers WA and the Mental Health Carers Issues Network recently conducted research into the needs and issues of carers of people with mental illness. 1. What Is The Most Difficult Part Of Your Role As Carer? Emotional strain was identified by 52% of carers as being the most difficult part of their role as a carer. This resulted from feelings of uncertainty and fear about the future; the unpredictability and uncertainty of the consumers' behaviour; abusive, angry and intolerant behaviours; feelings of helplessness; the carer's own deteriorating personal health; the difficulty of letting go of the responsibility; and sense of isolation and loneliness. (McKeague B, 2003. Worried, Tired & Alone - A report of Mental Health Carers' Issues in WA. Briefing Paper)

(Carers WA, Western Australia, Submission #277)

Carers WA and the Mental Health Carers Issues Network recently conducted research into the needs and issues of carers of people with mental illness ...What impact has being a carer had on your life? The majority of carers (88%) reported a negative impact that being a carer has had on their life. Loss of personal, physical and emotional freedom, and restricted social and work opportunities was identified by 30% of carers. Impact on family dynamics was the second most frequent response to how caring had impacted their life (25%). There were effects on children and siblings, disturbing family emotions, difficult relationships with partners, and marriage breakdown. Other negative impacts included personal illness, tiredness and sadness (22%). (McKeague B, 2003. Worried, Tired & Alone - A report of Mental Health Carers' Issues in WA. Briefing Paper)

(Carers WA, Western Australia, Submission #277)
6.5.8.3.4 Police

Due to diminishing access to mental health services, police have been increasingly called to assist with people with mental illness, especially in times of crisis. In some places, Memorandums of Understanding (MoUs) have been drawn up between police and mental health services and training has also occurred, but evidence suggests that further consultation is required to more clearly define police involvement with people with mental illness and acknowledge the limitations of their involvement. Additionally, involvement of police to assist with people with mental illness increases the stigma that ensues from police contact and heightens community fears, in what should be a mental health response:

The police have a MoU with SW [South West] Health and we are working on positive steps to address the issue.

(Police officer, Western Australia, Bunbury Forum #11)

The last thing we want to do is get involved with mental health issues but we have a legislative requirement to get involved. One thing that concerns me personally is the transport of people with a mental illness. We are often required to transport these people but they are not criminals, they are ill.

(Police officer, Western Australia, Bunbury Forum #9)

(In response to question How do the Police behave? Are they adequately trained? Do they know what they are doing?) Yes but they don't always give it a high priority therefore things can get out of hand in the time it takes for them to respond. They are sometimes short staffed. We need to have more trained people on the ground.

(Carer, Family member, Western Australia, Geraldton Forum #51)
6.5.8.3.5 Lack of housing and accommodation options

The lack of accommodation, and in particular supported accommodation, options was repeatedly raised in submissions and at forums. The increasing demand on current services and their increasing inability to deal with clients with complex needs (e.g. mental illness) due to lack of resources is resulting in increased homelessness, increased pressure on families with little or no available community support, and additional barriers for the successful rehabilitation and reintegration of the person with mental illness into the community. As evidenced in the following quotes, coordination with the Department of Housing is urgently needed to address this critical issue to provide both sufficient accommodation in conjunction with the Department of Health and also to provide mental health treatment and support for people using supported and crisis accommodation services to ensure specialised and coordinated care:

We have 12 houses and a boarding house for single men so we can take in 18 men. I have worked in human services for the last 16 years and I can tell you that we are now on a path to disaster - people are being 'dumped' on our service and on the streets because other people don't know what to do with them. They are sent here by the service or the hospital with no consultation with us - they are just told where to go, how to find us.

(Service Provider, Western Australia, Bunbury Forum #12)

We had a client who was suicidal a few months ago. When contacting the mental health service during the day time - because the worker would not give a surname, (our workers do not give out their surnames) they hung up on her. We managed to get her to Perth for help. About six weeks later I contacted them and gave my full name and she laughed at me, because she didn't believe it was my real name - my surname is [Y] - She laughed at me and said that that was not my real name and hung up on me. I was told that it was Domestic Violence and it was not mental health.

(Service Provider, Western Australia, Geraldton Forum #89)

...advised of the availability of two units for consumers ...the units are much needed as at the moment most local consumer have to remain living at home in what for some is less than favourable circumstances, the alternative is for them to move to Bunbury or at least Busselton which means leaving support networks of family and/or friends ...approached the Health Department seeking funding for an appropriate support worker to service these units we were advised, after the 2004 review of NGO funding the Minister had withdrawn and further funding application and therefore we were not able to provide a support service to the units and they were turned in.

(NGO Service Provider, Western Australia, Submission #45)

Further for three consecutive years [Y] did not even receive CPI [Consumer Price Index] increments to assist in provision of services ...the health department their response was to suggest [Y] do what other organisations have done and reduce service. To this agency this makes no sense ...therefore to continue offering quality service I have staff members in their own time fundraising for ...much needed items.

(NGO Service Provider, Western Australia, Submission #45)

We are also now in the position where we are housing people when properties become available, without the capacity to support them in their housing. In 2002, NGO's were invited by the Office of Mental Health to tender for disability support services. Many I know worked extremely hard to put in their submissions, only to be advised in writing the following year, that no funding would be forthcoming ...This organisation has recently approached The Gaming Community Trust Grants Program to request funding for the growing number of children in the Program, which now totals 40. So much work has been completed through the COPMI [Children of Parents with Mental Illness] Project in WA, yet the children remain unsupported. Unfortunately, the application was not successful and we have been referred to DCD and Lotterywest to pursue the Project, a Project I believe that Mental Health should be funding as part of an early intervention and prevention strategy. I do not think that the Office of Mental Health appreciate the lengths to which many NGOs go to try and come up with innovative ways to support this group of people and many of the workers in mental health in WA are extremely united and dedicated.

(NGO Service Provider, Western Australia, Submission #18)

In November 2001, St Bartholomew's House wrote to the Premier of WA, Dr Geoff Gallop, to highlight some of the difficulties they were experiencing in caring for people with mental illnesses. At that time the Supported Accommodation Assistance Program (SAAP) service had over 60% of the 54 residents with a known mental illness ...Dr Gallop asked that a number of government officers from both mental health and SAAP services meet with St Bartholomew's House to discuss possible solutions. After 14 months of deliberation a report was written and St Bartholomew's House was provided with an additional $30,000 of SAAP funds but there was no money from mental health.

(St Bartholomew's House Inc, Western Australia, Submission #37)

6.5.9 STANDARD 9: SERVICE DEVELOPMENT

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

Until we erase the current culture of poor Health governance in W.A., unfortunately we will not move forward. For example, local doctors were excluded from participating on the local Hospital Board from the mid 1990's, and the Hospital and Health Department have ignored, or been unwilling to accept our advice on all matters medical, for many years ...Government cannot continue to blame lack of staff for our current Mental Health care problems. Any money thrown at the current system without a fundamental change, as outlined, will not work.

(GP, Western Australia, Submission #326)

Under this Standard, submissions and presentations indicate concerns about:

  • the current state of service delivery in Western Australia;
  • consumers, carers, staff and service providers not involved in planning and delivery of services;
  • lack of planning to provide continuous care;
  • lack of resources to deliver quality mental health care;
  • services ever diminishing in rural and regional areas;
  • problem with 'custody and control' model of care;
  • funding model needs to change;
  • lack of funding to NGOs;
  • Impact of lack of resources on staff and recruitment and retention;
  • staff training and development needed;
  • need for more graduate programs and supervision for mental health nurses;
  • problems with accountability; and
  • private vs public mental health services.

6.5.9.1 Current state of service delivery in Western Australia

Many submissions and presentations at forums conveyed feelings of despair that since the Burdekin Report and the closure of institutions and promise of community care, services have been declining and deteriorating rather than improving:

The only people we can rely on are the police who always respond but then they are left with nowhere to take him due to the appalling state of the mental health services and lack of facilities.

(Carer, Mother, Western Australia, Submission #13)

National Mental Health Plan 2003-2008 ...Page 16 ...Increasing service responsiveness?! 'The system' couldn't be any less unresponsive if it tried.

(Carer Advocate, Western Australia, Submission #339)

What have we got for a mental health system? Nothing, absolutely nothing! My support group helps me but not the mental health system.

(Consumer, Western Australia, Bunbury Forum #1)

Unfortunately, in more recent years positive change does not seem to have continued, and if anything, deterioration has taken place. Now, at least in Western Australia, there is a crisis in regard to provision of Mental Health Care within the community.

(extract from a letter to Communications Manager, Mental Health Council of Australia)
(Clinician, Western Australia, Submission #24)

I am a consumer of mental health care and I would like to say that since the new Mental Health Act has been introduced things have gotten much worse. I was better off before. When I get sick I will be looked after for a month and then there's nothing else for me - no care. The local government providers say I should go to the GP for care because I don't have a mental illness - I have temporal lobe epilepsy.

(Consumer, Western Australia, West Perth Forum #27)

...consultations into mental health care in Australia ...is particularly important and necessary in Western Australia due to the dire state of mental health care from years of neglect and under funding of mental health services.

(Carers WA, Western Australia, Submission #277)

On a personal level, working in the APU [Acute Psychiatric Unit] provides a lot of anxiety for me at times. I feel there is no commitment by the hospital to provide a high standard of care for the mentally ill, funding is lacking, and the issue of safety, being an expensive one, does not hold high priority for the hospital or the current government.

(Clinician, Western Australia, Submission #55)

During the last 28 years I have practised as a GP in Geraldton. The provision of mental health has at best been poor to fair, and at the worst been atrocious.

(Clinician, Western Australia, Submission #326)

...the terrible shambles that SW MHS [South West Mental Health Services] has become.

(Clinician, Western Australia, Submission #19)

Carers fill the gaps in the system, providing the care and support for their family members and friends with mental illness who are unable to access the services they need. Without Carers, the system would collapse.

(Carers WA, Western Australia, Submission #277)

I suspect the increasing rates of imprisonment may be linked to the deinstitutionalisation of men and women from mental health facilities. As well as the inability of existing services to provide holistic health care arrangements that see drug use as a symptom of mental health issues and not always the cause.

(Service provider, Western Australia, Submission #14)

The good news from the same committee [Standing Committee], which I happen to chair, is we have decided to conduct an inquiry into the adequacy of Mental Health Funding in Western Australia. The terms of reference will be to enquire and report on the level of need and adequacy of funding for Mental Health Services in Western Australia.

(Dr Christine Sharp, MLC, Western Australia, Submission #3)

Mental Health Care in WA is a disgrace. The system is chronically under-funded and under-resourced. There is a chronic shortage of psychiatric beds. Community Clinics are overworked and under-resourced. Supported accommodation options for mental health clients are severely lacking. The Psychiatric Emergency Service is viewed as a joke by clinicians and clients alike and function as little more than a telephone advisory service.

(Clinician, Western Australia, Submission #4)

It is an unhealthy system that allows even a minority of its parts to operate in ways that are so hostile to its service users and against its own mandate.

(Health Consumers' Council WA, Western Australia, Submission #29)

I do not want what I have to say as being service bashing because I believe that a lot of service providers are endeavouring to do their best with limited resources and are often hampered by what I see as bureaucratic processes which can no doubt be justified by bureaucrats. I see it very much as a political issue with inadequate funding being a substantial cause of the ongoing problems.

(Carer Advocate, Western Australia, Submission #339)

I have pulled my wife out of the Public Mental Health system - I feel the Public Mental Health system should only be used in emergencies as a last resort.

(Carer Advocate, Western Australia, Submission #339)

The Gallop government drew appalled criticism from all around Australia when it actually cut funding to mental health services in 2003. There is no indication it acknowledges the scale of the severe crisis in mental health services in WA or the need to commit sufficient resources to address it. Yet as the Department of Health admits in its 2004 discussion paper, 'clinical community support for people with mental illness is inadequate to provide effective case management and discharge planning ...services they require either do not exist or are insufficient'.

(SANE Australia, National, Submission #302)

The WA Office of Mental Health has established a Branch solely to examine reform and redesign issues, based on WA's Mental Health Strategic Plan 2004-08. Any action, however, will depend on the Gallop government which has been defensive and reluctant to commit itself seriously in this area.

(SANE Australia, National, Submission #302)

A 2004 discussion paper, Enhancing the Capacity of Mental Health Services, suggests improved support for psychiatric services in hospital Emergency Departments and some other measures - but seems a despairing, hastily-composed document listing more problems than solutions.

(SANE Australia, National, Submission #302)

There are continuing problems in regard to the integration of the APU [Acute Psychiatric Unit] into the management structure of the Bunbury Regional Hospital. It is by no means clear that senior management staff have a good grasp of issues to do with mental health and psychiatric clinical service delivery. Despite principles of integration and mainstreaming there still is a tendency for psychiatry to be treated differently to other medical specialities ...

(extract from a letter to the Office of the Chief Psychiatrist) (Clinician, Western Australia, Submission #24)

6.5.9.2 Consumers, carers, staff and service providers not involved in planning and delivery of services

Failure of the hospital to maintain the progress apparent in other states, to involve consumers not just in representation on committees but at a clinical level. This inaction has ensured that a philosophy of consumer focused care (as recommended by the Mental Health Strategy) has not taken root and that the culture of stigmatisation (devaluing and dismissive attitudes and behaviours) of consumers has prevailed. (Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)

(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

Another overriding theme in many submissions was the widespread decline or cessation of consultation with consumers, carers, clinicians and service providers in the planning, implementation and evaluation of MHS (Standards 9.8 and 9.9). Service providers in particular expressed feelings of complete frustration and helplessness and reported further reduced ability to deliver treatment and support services to people with mental illness:

Senior clinicians have lobbied the Office of Mental Health and the Health Minister but their concerns fall on deaf ears.

(Clinician, Western Australia, Submission #4)

Over the years I, and many colleagues, have attempted to resolve identified problems of clinical service delivery through traditional channels of communications within the Health Department. I have to confess that I have been singularly unsuccessful in achieving much change. (extract from a letter to a Member of Legislative Assembly)

(Clinician, Western Australia, Submission #24)

The part-time role of clinical director is being marginalised. This, in my opinion, is quite unfortunate as such a role can play an extremely important part in relationship to matters of clinical governance and to the integration (rather than separation) of administrative and clinical matters ...(extract from a letter to the Office of the Chief Psychiatrist)

(Clinician, Western Australia, Submission #24)

It was on the 1st of April that SouthWest 24 became the main point of contact for Bunbury people needing mental health care. There was no consultation with the community before the service was closed. We simply received a letter advising us of the changes!

(Clinician, Western Australia, Bunbury Forum #6)

I'm a service provider and we didn't even receive a letter!

(Service Provider, Western Australia, Bunbury Forum #7)

We received a letter informing us that there were no longer any mental health services in Bunbury and that we would have to use SouthWest 24. We were told there would be a response if there was an emergency.

(School counsellor, Western Australia, Bunbury Forum #8)

...[Bunbury clinic] was recently allowed to close ...I hope that the MHCA was aware that there was no consumer representation on any body that allowed such a tragic act to occur in our town. I can certainly say that the clinicians working in this area are totally frustrated and saddened by the inattention to community mental health issues by SW Area Health. In my view this reflects a serious disconnection between the health service management, clinicians and consumers that I fear may never recover under the current administrative structure.

(Clinician, Western Australia, Submission #19)

Youth mental health services ...The situation is very poor and we rarely receive information about what's happening with services.

(School counsellor, Western Australia, Bunbury Forum #8)

There's disconnection between GP's and us. These findings have been identified and re-identified but nothing is being done. Perhaps the greatest disconnection has occurred between the consumers, the providers and the decision makers. Consumers are no longer being consulted about their needs here. It was 12 months ago that we clinicians wrote to the District Director advising of problems with the mental health clinic. Nothing was done!...The clinicians don't want to work like this but we are forced to work in crisis-mode.

(Psychiatrist, Western Australia, Bunbury Forum #15)

SouthWest 24 has been around for quite a while as a private company - it used to work reasonably well but the problems occurred earlier this year when it became the single point of entry into the system! One of the biggest problems was in how the information was communicated. Our organisation had a MoU [Memorandum of Understanding] with the local mental health service about how we would work together to better deliver mental health care. That was changed unilaterally by the mental health service - so that's left us (general practice) feeling pretty bad and pessimistic about trying again.

(GP, Western Australia, Bunbury Forum #19)

There is a plan for Diabetics, Asthmatics for their drug use etcetera. But we have systemic problems with mental health since I came to Geraldton in 1997. The Division [Mid Western Division of General Practice] funded another health worker. The box was ticked - your concern has been heard - but no change. Lots of meeting where we are told why they can't do things. Nothing happens. As for GPs' referrals, a large proportion of my patients have mental health problems.

(GP, Western Australia, Geraldton Forum #62)

Issues of Bunbury Mental Health Services:

•  Clinic ceased functioning at Molloy Street 29/04/04, 9 weeks ago at 1/7/04

•  No notification was forthcoming to consumers until 10/06/04, when a mail out was done after the consumer carer group insisted on this.

•  There has been no consumer consultation of any kind in respect to the plans, location and functioning of the new clinic. It has been acknowledged that this should happen but nothing has been forth coming. Costing for renovations are currently before the director general for approval. At what point will consumers be involved in the planning process?

•  It has been suggested that the rehabilitation program (living skills) will be co-located with the new clinic. Consumers have not been given an opportunity to discuss the appropriateness of this.

(Advocate, Western Australia , Submission #2)

Issues of Bunbury Mental Health Services:

•  Basically decisions are being made behind closed doors, top down management with no consultation on anything. Consumers are getting angry at placating comments, and lack of real response to concerns over lack of service. Needs are not being met in anything but the most reactive way. There is a general perception that moral is universally declining along with confidence. The analogy of the titanic describes the emotion of most people involved.

(Advocate, Western Australia , Submission #2)

Unfortunately, no matter what clinicians say or do, it is managers within the various systems that control budgets and therefore the important resource requirements. The system in Western Australia now is such that it is as though a divide exists between managers on the one hand and clinicians on the other. (extract from a letter to Communications Manager, Mental Health Council of Australia)

(Clinician, Western Australia , Submission #24)

6.5.9.3 Lack of planning to provide continuous care

Standard 9.4 states: 'The organisational structure of the MHS ensures continuity of care for consumers across all settings, programs and age groups'. However, evidence indicates that the MHS is not providing and supporting continuity of care in multiple ways; e.g. by declining to fill key critical positions even when ample advance warning of departure was known and the implementation of restrictive policies. One accommodation service provider reported that when the service had approached the WA government for assistance to provide services for people who are homeless and have a mental illness. However, not only was their request denied, but they were also told to "just move these people on".

There is no child psychiatrist in the area and the service knew for about 12 months that he was leaving. Nothing has been done that I can see to replace him.

(School counsellor, Western Australia, Bunbury Forum #8)

I would like to talk about two main things. In August 2003 at the Mental Health Forum in Dongara the question was put regarding the money designated for a second psychiatrist for Geraldton had been taken out of the mental health service and put elsewhere. We were assured that we would still get another psychiatrist next year. However, a short time later I was informed that that was no longer going to happen.

(Mental health worker, Western Australia, Geraldton Forum #56)

We run a 20 bed aged care and crisis service for people with a mental illness. 18 months ago we had to restrict the number of people with a mental illness coming into our service. I'm not proud of that but we were having too many problems and incidents with those people we identify as the "hard homeless" - they are difficult to care for, they don't pay but where do they go? If you are homeless, with a mental illness you don't get help from anywhere, you don't have a pension because you can't comply with the rules and regulations and most often there's nobody advocating for you. These are the forgotten people! When we've asked government for additional support for these people we've been told we should just move these people on.

(Accommodation Service Provider, Western Australia, West Perth Forum #33)

This loop hole in the referral process can for many mean they will have no daily support networks and will be totally reliant on GP visits or repeat calls to South West 24 Services for any contacts or support.

(NGO Service Provider, Western Australia, Submission #45)

6.5.9.4 Lack of resources to deliver quality mental health care

We now have access to the lowest cost health service! Not only do we have to tolerate the closure of our mental health service but ever diminishing resources. My experience is that we have extremely diligent staff and GP's but there simply isn't enough money or resources to support them in delivering quality mental health care.

(Carer, Western Australia, Bunbury Forum #14)

The lack of resources to deliver treatment and support services to people with mental illness and intervene at the earliest possible moment was a theme expressed repeatedly throughout many submissions and at all the three Western Australia community forums. Claims were made that the MHS was focusing on beds (end crisis point) and not community services (early intervention) and resources were not being allocated to reflect national mental health policies (Standard 9.14) or in a manner which allows the MHS to respond promptly to the changing needs of the defined community (Standard 9.15). Comments indicated that services are barely able to deliver basic services or treatment which requires minimal support (e.g. medication was the only treatment option).

I feel that the public system is over worked, psychiatrists aren't well trained and they don't have the resources they need to be able to respond properly.

(Consumer and Carer, Western Australia, West Perth Forum #34)

A pathetic 12 extra beds won't solve anything.

(Carer, Husband, Western Australia, Submission #146)

...services in the lower south west there is a mental health clinic located at Bridgetown which often only opens one or two days per week. This clinic is up to one hundred and twenty kilometres away from some of the towns it services and often further for those living on remote properties. There are two mental health nurses who service this region and they are greatly stretched, making quality contact time impossible.

(NGO Service Provider, Western Australia, Submission #45)

If I was a client and needed help I'd now be forced to phone SouthWest 24 for help. I would then be referred to triage services and my situation/problem would be discussed at an intake meeting. I went to an intake meeting recently and it was a scary process in the way that decisions were being made that would result in clients being excluded from care - not because they didn't need care but because of a lack of resources.

(Mental health worker, Western Australia, Bunbury Forum #16)

I think it needs to be recognised that a lot of the people who provide care are family members - the carers - when my sister needs care she doesn't contact SouthWest24, she comes to us. The service providers are good people they just don't have the resources they need. It's very hard, very difficult.

(Sister, Western Australia, Bunbury Forum #25)

Carers consistently report that mental health services are inadequate and their family members can't get access to services when needed. On these occasions the responsibility for care and management is transferred onto the family carer who tries their best to manage and provide the care and support that is not available through mental health and community services. Without this sustained contribution from carers, the mental health system which is already under extreme pressure would be placed in greater jeopardy.

(Carers WA, Western Australia, Submission #277)

Carers report that the current funding and provision of mental health care in WA is clearly inadequate to meet the level of need. This is demonstrated by: People unable to access community mental health services unless they are in crisis and are a threat to themselves or others; People presenting at hospital emergency departments requiring treatment for mental illness waiting in corridors as beds are not available in psychiatric hospitals; The lack of independent accommodation options for people with mental illness. There should be a range of options available and flexible to the individual needs of people with mental illness.

(Carers WA, Western Australia, Submission #277)

As a result of our enquiries into this area, we were made increasingly aware of the incredible reduction in the amount of care in almost every area which affects mental health treatment. Doctors and nursing staff are struggling with ever mounting burdens of care, while working with continually decreasing resources in Graylands Hospital and the mental health clinics. When our son was first admitted to Graylands Hospital in 1990, there were approximately 300 beds available. Now, after several wards have been closed, there are only 197 beds, of which 30 are in a separate locked forensic ward (built in about 1995), and hence are not available to the general public!! As Perth has grown in leaps and bounds with an ever increasing population, and therefore by extension, ever increasing numbers of mentally ill people of all ages, the amount of available care has been significantly reduced by successive governments, and particularly so in the past few years.

(Carers, Parents, Western Australia, Submission #76)

The third area of neglect is the overburdening of the mental health clinics themselves whose staff, despite the best of intentions are virtually unable to offer more than just basic supply of medication and an occasional doctor's appointment (usually in over a month's time - hardly ideal for fragile patients). Patients will occasionally get a home visit from a nurse, but as there is no interim accommodation as detailed above, this is completely inadequate in most cases.

(Carers, Parents, Western Australia, Submission #76)

I feel the inpatient unit in Bunbury provides a second-rate service to the mentally ill in the region as it does not provide a multi-disciplinary team.

(Nurse, Western Australia, Submission #55)

Although St Bartholomew's House continues to try and provide a quality service in supported accommodation (SAAP), the lack of resources, a staff ratio of 1:54, poor education of staff and the numbers of people requiring care limits the capacity to delivering safe quality care.

(St Bartholomew's House, Western Australia, Submission #37)

The WA State Mental Health Strategic Plan 2004-2008 highlights that 371 staff are currently needed to meet accepted benchmarks and 233 beds are currently required to meet benchmarks. By 2008 we will need an additional 559 staff and an additional 368 beds. (author's emphasis)

(Clinician, Western Australia, Submission #4)

Resourcing has now become critical. This is well exemplified in Western Australia by the absence of sufficient emergency beds for those who are acutely unwell with serious psychiatric conditions. (extract from a letter to Communications Manager, Mental Health Council of Australia)

(Clinician, Western Australia, Submission #24)

6.5.9.5 Services ever diminishing in rural and regional areas

Concern was expressed regarding the continued reduction of treatment and support services in rural and regional areas rather than strategies to enhance and improve service delivery. Consumers, carers and the few service providers operating in these areas with minimal support reported negative impacts of the result of such planning:

...the Midwest Mental Health Department was established. The aim of this organisation was OK, but its implementation and structure was flawed from the onset.

(GP, Western Australia, Submission #326)

...the supportive caseworkers withdrew their after hour's services completely, leaving effectively, no after hours psychiatric service in Geraldton ...The problems have therefore been:

•  An ineffective resident psychiatric service, both acute and non acute.

•  Management (local and Perth ) with questionable skills.

•  Poor methods of case handing.

•  Poor communication with local GPs.

The solutions are:

(1) A totally new Psychiatry system, involving a board consisting of GPs and a well trained autonomous psychiatrist.

(2) The psychiatrist should be highly paid with a right of private practice, and form his or her own team, and "run the show".

(3) The psychiatrist will report to the Board of Management at regular meetings, to assist in management decisions.

(4) Government should fund this initiative adequately, and heed the advice of the board.

(GP, Western Australia , Submission #326)

...I am constantly reminded of the additional problems for those families living in the more remote rural areas of the State ...how regionalising a service to a central area will have little or no benefit too them.

(NGO Service Provider, Western Australia, Submission #45)

...the decision to cancel the locum at the eleventh hour as an apparent gross error of judgement at best and, at worst, the demonstration of a callous disregard for the psychiatrically unwell who happen to suffer the additional disadvantage of living in a rural area ...the rural community served by it continues to suffer considerable disadvantage in comparison with residents of the Perth metropolitan area. Your recent intervention provides no comfort for a rural service that hopes to gain equity of access for its consumer base ...

(extract from a letter to the Director General, Health Department of WA)
(Clinician, Western Australia, Submission #24)

Changes to policies and procedures were reported as further complicating access to sparse resources in rural and regional areas:

...recently informed of the changes to the ...South West Mental Health Services procedure for referral of a consumer presenting unwell ...staff are to advise the person for whom they are concerned to either seek consultation with their GP or go direct to the local hospital where their details will be passed on to the SWMHS who in turn will forward these details to the South West 24 telephone service which is now the single point of entry for all consumers and Carers. Once these details have been received by the South West 24 worker they will contact the consumer by telephone and then they will triage them at this time. One concern is the probability of the client not having a contact number or home phone or even a home. If contact can be made the South West 24 worker will decide who the person should be referred to this may well be their GP who referred them in the first place or the South West Mental Health Services in their area. After this referral has taken place a referral an appointment will be made with the nominated service ...this process appears to be lengthy and could take several days for a potentially unwell client to be "seen" by a clinician. A concern for this organisation is the welfare of the client and the possible difficulties they experience during this referral period.

(NGO Service Provider, Western Australia, Submission #45)

...organisation through its contractual agreement with the Health Department of WA is directed to only take referrals from the SWMHS. However if clients are to be referred to their GPs for treatment then they will have no means of access to the Community Support Services in their area. This loop hole in the referral process can for many mean they will have no daily support networks and will be totally reliant on GP visits or repeat calls to South West 24 Services for any contacts or support. Again this tends to demonstrate the lack of communication or recognition of the NGO services providers.

(NGO Service Provider, Western Australia, Submission #45)

6.5.9.6 Problem with 'custody and control' model of care

As alluded to above, there is a belief by some that a shift has occurred to the model of care ('custody and control') underpinning resource distribution and the planning of service delivery. A focus on this model emphasises containment rather than treatment at the earliest possible time to prevent people requiring hospitalisation or entering the criminal justice system:

However any change being brought about, without a fundamental change in the value system of the culture of the hospital towards a more humanistic attitude to patients, is likely to be little more than tokenistic. (Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)

(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

I have been a consumer advocate in WA for many years. What I've noticed in WA is an emphasis on control rather than mental health care. The Government's response is a lock and key response rather than good mental health care. We need to emphasise the care as important and not building monuments to misery!

(Consumer advocate, Western Australia, West Perth Forum #28)

Culture of control, not therapeutic engagement. The WA mental health system has evolved within the treatment model, excessive use of medication and routine use of police in dealing with patients. There is room for debate on the attitudes and practices of mental health service workers and whether these social norms support punitive handling of mental health consumers.

(Health Consumers' Council WA, Western Australia, Submission #29)

6.5.9.7 Funding model needs to change

Associated with the complaints of lack of available resources to deliver quality mental health services, are requests and demands that the funding model needs to change in order that appropriate services are delivered and the rights of people with mental illness protected. Funding issues were raised both within the health budget and also as a whole of government package in the provision of support services for people with mental illness and their families.

"Western Australia spends about 7.5% of its health budget on mental health, although mental illness is thought to account for at least 20% of the economic costs of and premature deaths. Other first world countries invest 10-14% of their total health expenditure on mental health services." (WA Association for Mental Health, 2003). The Mental Health Carers Issues Network has concerns that ad-hoc funding commitments only address specific unmet needs areas in the short term and don't address systemic problems in mental health services and areas of unmet need in the long term.

(Carers WA, Western Australia, Submission #277)

While the immediate crisis may be alleviated by an injection of funds, a long term vision is required for mental health care in WA supported by a commitment and funding by government for future mental health care of Western Australians. In addition, clear accountability processes need to be put in place to ensure funding provided by the Commonwealth Government to the State Government for mental health programs is not redirected towards other general health areas and hospitals.

(Carers WA, Western Australia, Submission #277)

More money into mental health services will not make the difference without some changes to the fundamental assumptions that direct the current treatment paradigm.

(Health Consumers' Council WA, Western Australia, Submission #29)

If the metro is $118 and Geraldton is $70 per capita, I would think that Dongara would be about $1.50 per capita ...There is a lack of support for carers and acute clients.

(Anonymous, Western Australia, Geraldton Forum #108)

6.5.9.8 Lack of funding to NGOs

Concerns were also expressed about the insufficient level of funding diverted to the NGO sector and the manner in which funding is determined. Standard 9.15 states: 'Resources are allocated in a manner which follow the consumer and allows the MHS to respond promptly to the changing needs of the defined community'.

Non-government organisations which provide essential day-to-day community support to consumers and carers are not funded in any coherent manner, and were especially hard hit by the 2003 cuts.

(SANE Australia, National, Submission #302)

6.5.9.9 Impact of lack of resources on staff and recruitment and retention

Lack of resources, high demand and overstretched staff is also seen to be contributing to high staff turnover, recruitment problems, low morale and impacting on attitudes and behaviour of staff. All of these factors impact on the ability of the MHS to deliver 'a range of high quality mental health treatment and support services (Standard 11.4) and protect the rights of people with mental illness and mental health problems'.

Junior nurses and doctors are discouraged from pursuing careers in mental health due to the disgraceful working conditions that staff are forced to endure. This only compounds the problems of staff shortages.

(Clinician, Western Australia, Submission #4)

I confirm that there are continuing difficulties with the medical staffing of the Acute Psychiatric Unit (APU) at the Bunbury Regional Hospital...(extract from a letter to the Office of the Chief Psychiatrist)

(Clinician, Western Australia, Submission #24)

[Z], the other psychiatrist also contributing to the current roster, is reluctant to continue feeling that the role is not well supported and lacks parity with metropolitan arrangements. (extract from a letter to the Office of the Chief Psychiatrist)

(Clinician, Western Australia, Submission #24)

The South West Area Mental Health Service is also struggling with a number of other issues that relate rather more to resource allocation. Considerable population growth ...Staffing levels, however, have not changed a great deal over the last two or three years. In addition, there appears to be substantial change in regard to both the numbers of presentations and level of acuity of same...It is also probable that there are changes in morbidity patterns as well - for example, drug related disorders. (extract from a letter to the Office of the Chief Psychiatrist)

(Clinician, Western Australia, Submission #24)

Junior medical staff are voting with their feet, we've seen a dramatic reduction in the number of applicants psychiatry training. Also an increased drop-out rate once in and a massive shift towards immediate private practice post Fellowship ...

(Consumer Advocate, Western Australia, Submission #338)

6.5.9.10 Staff training and development needed

Standard 9.17 states that the MHS 'regularly identifies training and development needs of its staff' and Standard 9.18 states that the 'MHS ensures that staff participate in education and professional development programs'.

Concerns were expressed indicating a need for training and development to inform clinicians about the rights of patients and support services to assist consumers. Evidence was also presented that staff are in need of disability awareness and cultural competency training in order to change their attitudes and behaviours (decrease discrimination) when dealing with people with a mental illness and people with a mental illness from a non-English speaking background:

In Dongara the health service has just one nurse on at night. The question was asked if the nurses could have more training in mental health. It has been suggested but nothing is happening. If they have a problem with a mental health patient they are lucky to be able to call on an aged carer to help. My understanding is that there are people willing to undertake this training but nothing is happening.

(Mental health worker, Western Australia, Geraldton Forum #56)

Attitudes and work practices of managers and clinical nursing staff that perpetuate the culture of stigmatisation towards innovative staff within the NPDU [Nursing Practice Development Unit] by: Other staff, not involved in the changes, making devaluing and degrading comments both verbal and written to staff who were attempting to make changes in the NPDU.

(Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

But we are told by many practitioners that they don't work with interpreters so they can't access adequate care.

(Manager of mental health access service for refugees, Western Australia, West Perth Forum #36)

6.5.9.11 Need for more graduate programs and supervision for mental health nurses

Concern was expressed that many mental health nurses are not receiving supervision and that this could also be contributing to the difficulty in recruiting and retaining staff in mental health services. An inability to attract and retain staff contributes to problems of continuity of care with clients. Standard 9.20 states 'The MHS ensures that staff have access to formal and informal supervision' and 'the MHS has a system for supporting staff during and after critical incidents' (Standard 9.21). However, the evidence paints a different picture:

Despite the fact that mental health nurses are involved in a high level of intensive interaction with disturbed patients over prolonged periods of time no formal clinical supervision system is in place in WA. Clinical supervision would support them in coping with the demands placed on them and minimise the risk of burnout. Other groups such as psychologists, social workers and psychiatrists consider supervision as a crucial aspect in their professional development and support. (Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach

(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

The difficulty with the recruitment and retention of nurses working in the mental health field lies not with nurse education but with the inadequacy of support that is able to be provided for beginning practitioners after their graduation. The Health Department needs to provide funding for the inclusion of mental health nursing in graduate programs so that experienced nurses have the time to mentor the beginning practitioner. At present there is not program available in community mental health to nurture new graduates so that they have the opportunity to become experienced mental health nurses. In Geraldton, where both enrolled and registered nursing education takes place, some students from every enrolled nursing and registered nursing courses want to work in mental health but do not get the opportunity to join the mental health workforce because no graduate program in this area is funded. If Geraldton graduates want to work in mental health, they have to move to Perth to take part in the graduate program at Graylands Hospital. In addition, there are no positions for enrolled nurses in community mental health.

(Nursing Lecturer, Central West TAFE, Geraldton, Western Australia, Submission #222)

I work at TAFE. There is a shortage of mental health nurses. In every class that I have, some want to do mental health but are unable to get jobs in Geraldton. The time taken for training means mental health nurses are unable to get support because of pressure of work. They need support.
(TAFE Worker, Western Australia, Geraldton Forum #68)

6.5.9.12 Problems with accountability

Failure to ensure accountability jeopardises 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'. Problems with accountability also impede the resolution of complaints (as discussed in Standard 1) and inhibit processes which allow for continuous quality improvement:

A serious concern is the failure of the hospital to provide a means of holding people accountable and responsible for the performance of others by: (a) Managers and the CNS failing to monitor and exercise control in maintaining the operation of initiatives agreed upon, on the ward ...(b) Senior nurses not being held accountable for decisions they had agreed to implement ...Concern - Managers and the senior nurses in the NPDU [Nursing Practice Development Unit] showed poor management skills in the areas of accountability, responsibility and leadership.

(Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

The prevailing culture of the hospital meant that staff, who reported unacceptable behaviours displayed by other staff on the NPDU, were unsupported and frequently ostracised ...One nurse was told by another nurse that she was wrong to report a staff member found to be abusive to a patient. The way of the hospital was to stick together (mateship) and not to "rock the boat" ...The current system of complaints procedure should be changed to allow greater flexibility in reporting. (In some incidents members of staff feared repercussions in approaching the direct line manager). The system should also ensure a greater degree of confidentiality that would minimise the practice of junior nurse managers discussing with ward staff the subject of the complaints. The process and outcome of each complaint should be reviewed using an independent system within a specified timeframe. (Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

6.5.9.13 Private versus public mental health services

The following presentation made at the forum held in Geraldton is an alarming reflection of a consumers' experience of both public and private care today in WA suggesting that the only way to access quality care is to have the resources to purchase it in the private sector.

I attempted suicide - I owe my life to the clinical psychologist that attended to me. I pleaded with my wife not to send me to Graylands where they wanted to send me. I was fortunate I had health cover, I was diagnosed with Bipolar. The last five months I spent two lots of one month in the Perth Clinic. I was lucky enough to be able to afford to do this ...The clinic here saved my life.

(Consumer, Western Australia, Geraldton Forum #61)

6.5.10 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:

  • the lack of coordinated, comprehensive and accessible documentation systems; and
  • the system does not allow continuity of care across settings.

6.5.10.1 Lack of coordinated, comprehensive and accessible documentation system

Standard 10.5 states: 'Documentation is a comprehensive, factual and sequential record of the consumer's condition and the treatment and support offered'. Varied problems however were reported with documentation systems ranging from problems with the amount of time required to complete paperwork, incomplete record keeping, failure of systems to retrieve records quickly enough and lack of continuity of care across settings. Reports received through the forums and submissions indicate that these problems complicated the delivery of appropriate and timely treatment and support and potentially compromised the safety of consumers:

There are now so many extra forms that the clinical have to spend most of their time with administration instead of their counselling job.

(Consumer, Western Australia, Geraldton Forum #61)

Several months following the creation of the Coordination Committee there was an audit of the activities of the ward by a senior nurse manager and the professor of mental health nursing. It found that although some of the changes introduced have been maintained a number had been modified or abandoned ... Hand-over sheets, information sheets to patients, allocation files, medication sheets, information boards were rarely used and not fully replenished or when used were not completed systematically or consistently.

(Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

The Community Mental Health Team from the Perth Hospital provides support to the Hostel with clinical services but each nurse's workload is considerable and if a person is unwell they are often not able to get them an inpatient bed. Nurses refill dossett boxes and mange medications but are reluctant to write in residents files when they visit or medicate residents. This puts residents at risk because St Bartholomew's House staff do not know what is going on if a resident has an adverse reaction to a treatment or whether he has had his regularly injection. All care plans are kept in the hospital.

(St Bartholomew's House Inc, Western Australia, Submission #37)

There may be a problem with the fund shifting from State to Commonwealth governments and the way prescriptions are handled. A couple of weeks ago I went to the hospital for medication. I was put on a chair and I had to spend 1 ½ hrs lying on the floor as I fell off the chair because I felt very dizzy.

(Consumer, Western Australia, Geraldton Forum #79)

I have a friend in trouble who threatened to kill her daughter. I phoned SouthWest 24 and they told me to phone the police ... she was taken away. The following day a nurse from the service phoned me and asked me where the woman was - she was in hospital! The nurse didn't even know she was in hospital - there's no coordination! My friend wasn't under a section but she was in hospital ...

(Friend, Western Australia, Bunbury Forum #3)

6.5.10.2 System does not allow continuity of care across settings

Reports that systems were not allowing for documentation to be accessed across settings indicate a serious impediment to accessing urgently required care. Standard 10.4 states 'A system exists by which the MHS uses the individual clinical record to promote continuity of care across settings, programs and time'. In many instances, consumers and carers spoke of documentation systems which had been working to provide care across settings, programs and time, suddenly being changed or stopped without adequate explanation or alternative arrangements being implemented:

My brother has done the hospital shopping in Perth looking for help. What this means is that his current case notes are not available, the person (Me) who supports and follows his medical care and history, has been until now unable to speak with doctors to share valuable, timesaving, costsaving information that would support my brother more effectively with his care.

(Carer, Sister, Western Australia, Submission #101)

There have been problems with the hospital since the changes six months ago. Before my doctor had a chart with my details at the hospital and I could obtain the medication when I needed it without waiting, it was OK. Now that has been abolished and because there are different doctors each time, it takes five or six hours for me to tell everything again before I can get my medication. In this time my condition is getting worse.

(Consumer, Western Australia, Geraldton Forum #79)

Also my doctor writes a letter for me when I go on holidays to Port Hedland I present the letter to the hospitals along the way if I am in need of medication and they supply it. I asked my doctor to do the same for me for here - when I presented the letter it was just ripped up. They just don't want to know.

(Consumer, Western Australia, Geraldton Forum #79)

My son who is 42 suffers from a mental disorder and has had several episodes over the past 25 years. He is presently living in his own house, on my property and has done so for several years. For some time now he has been treated for his condition by injection at home. On Thursday, August 19, 2004 he commented that he thought he felt another episode coming on. My wife then contacted the local mental health office and was advised that it was no longer possible to treat our son as in the past and that we would have to see Dr [Y]. An appointment was made for August 27 2004. We attended this appointment and were told no treatment would be administered until our son was assessed. This we were told might result in our son being placed on community order and admitted to hospital - presumably Graylands.

(Carer, Father, Western Australia, Submission #175)

6.5.11 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.

In summary I have no confidence in Mirrabooka MHS to deliver a timely, quality and responsive service. It's service is simply substandard - patients are treated like 'just another problem' to be solved and got rid of as soon as possible.

(Carer, Husband, Western Australia, Submission #146)

Evidence presented indicates that the mental health system in WA is failing to deliver care according to the six principles of care: (1) choice; (2) social, cultural and developmental context; (3) continuous and coordinated care; (4) comprehensive care; (5) individual care; and (6) least restriction. This is supported by reports of lack of access to any care (and therefore no choice), lack of service for youth, the elderly, people from a NESB and Indigenous people; lack of continuous and coordinated care (again, due to problems of services, limited resources and crisis response-driven access); lack of comprehensive care (due to an inability for consumers to access services during the onset phase, lack of access to rehabilitation services, and an overall inability to access mental health services); lack of individual care (for the reasons just mentioned); and as there are reports of a focus on containment and control, this indicates that treatment and support is not the least restrictive:

Trying to help people seek help - what will they get?

(GP, Western Australia, Geraldton Forum #62)

Closure of South West Community Mental Health facilities to the public due to the unsafe condition of the building. This closure has prevented [X] from obtaining adequate and confidential assistance and treatment locally.

(Carers, Western Australia, Submission #177)

Culture of custody and control which is prevalent in WA. Part of the culture of control is the resistance to addressing a person - civil liberties.

(Consumer Advocate, Western Australia, West Perth Forum #36B)

I had an incident a while ago when I went to hospital in Bunbury, I was put aside (waited) a couple of hours - I wanted to go home but the hospital wouldn't let me go. I finally went home and a few hours later the police came to take me back to the hospital. I went willingly and saw the doctor who said I needed an injection. I was threatened that the police would hold me down while I had the injection so I agreed to have it. After they injected me I was taken to Graylands Hospital in Perth but nobody informed my family of my admission to Graylands.

(Consumer, Western Australia, Bunbury Forum #1)

6.5.11.1 Access

The MHS is accessible to the defined community.

Under this Standard, submissions and presentations indicate concerns about:

  • an inability to access services when needed;
  • police response is the only response - police are the de facto mental health service;
  • lack of access to care - "right to get care, not be arrested";
  • access denied due to past forensic status;
  • access denied due to history of sexual abuse;
  • no access to any MHS - regional location;
  • lack of access to care - regional area - transportation issues;
  • phone service is the only contact with MHS service;
  • access denied for consumers with intellectual disability;
  • lack of access to treatment and support services for people with Personality Disorders; and
  • difficulty accessing psychiatrists and psychologists.

Concerns were expressed across Western Australia that mental health services are not available on a 24 hour basis, seven days per week (Standard 11.1.4). Consumers and carers repeatedly reported examples of failure to gain access throughout the course of their illness or even when in extreme crisis.

An inability to access services was the catalyst for potentially infringing a whole series of other rights for consumers, carers and the community. For the consumer, the infringement of these rights resulted in increasing disability and hence consequent inability to participate socially or work and study, and in some cases, the potential for harm to self or others, or becoming homeless or poor. For children and youth, failure to gain access at this time of their life placed their future life course at risk.

Similarly, increased burdens on carers as the mental health of consumers deteriorated resulted in carers being unable to participate socially and work. Family isolation and increasing instability were also frequently reported due to lack of community support and acceptance (high levels of stigma and discrimination). For the community, rights to safety were potentially infringed upon and social and economic cohesion disrupted.

6.5.11.1.1 Can't access services when needed

I ask the following questions: If a patient develops an acute abdomen and possibly has appendicitis the patient can be transported to an [sic] hospital emergency department. There is no requirement to establish that a bed is available. If a patient develops severe chest pain and may be experiencing a heart attack, again, the patient is transported to an [sic] hospital emergency department for further assessment and treatment. It is not necessary to establish the availability of a bed. Why is it that acutely unwell psychiatric patients in emergency situations are treated differently? How does this reflect equity of access to high standard clinical care? (extract from a letter to the Director of Community Mental Health Programme)

(Clinician, Western Australia, Submission #24)

A constant theme throughout many submissions was not only an inability to access services when needed, but that access was also difficult even when consumers are at risk of self harm or harm to others:

National Mental Health Plan 2003-2008 ...Page 20 - "Outcome 8: Improved access to acute care". Well, it couldn't get any worse from here if treating psychiatrists are 'too busy' to see suicidal patients!

(Carer Advocate, Western Australia, Submission #339)

I make the following observations: Had an emergency bed been readily available then the Mental Health Act could have been rapidly implemented with the support of the Police, this would have prevented the escalation of a difficult clinical situation. It would have minimised risk to all concerned. A much better quality of clinical care would have been provided to the patient in line with psychiatric best practice ...(extract from a letter to the Director of Community Mental Health Programme)

(Clinician, Western Australia, Submission #24)

Why on earth are consumers who are exhibiting signs of a relapse not taken seriously? Why is it that the consumer needs to be either psychotic, suicidal, or in some other emergency before they are seen and treated? (author's emphasis)

(Carer, Husband, Western Australia, Submission #146)

They must be [an] emergency to be admitted, if not the already overburdened and underfunded/resourced community teams have to try and maintain them, but in reality it is more likely to be the family / carer and the GP. There is no room for innovation, just relentless grind: the culture of therapeutic nihilism is now deeply ingrained. Staff fight with staff, barriers to service access are getting higher and higher.

(Consumer Advocate, Western Australia, Submission #338)

The psychiatric nurse agreed with my wife that she required urgent treatment and assessment - the psychiatric nurse went in to personally ask Dr [psychiatrist] if he could see her. He refused to do so! I find this outrageous. We ended up in [Z] ED [Emergency Department] yet again ...

(Carer, Husband, Western Australia, Submission #146)

Carers report that the current funding and provision of mental health care in WA is clearly inadequate to meet the level of need. This is demonstrated by: People unable to access community mental health services unless they are in crisis and are a threat to themselves or others.

(Carers WA, Western Australia, Submission #277)

This leaves us as carers and in the worse case scenario, the general public at large, in a very vulnerable position. We no longer have any faith that the PET team will respond as we have rung many times, over the years but they cannot attend so we don't bother to ring them anymore.

(Carer, Mother, Western Australia, Submission #13)

...recently informed of the changes to the ...South West Mental Health Services procedure for referral of a consumer presenting unwell ...staff are to advise the person for whom they are concerned to either seek consultation with their GP or go direct to the local hospital where their details will be passed on to the SWMHS who in turn will forward these details to the South West 24 telephone service which is now the single point of entry for all consumers and Carers. Once these details have been received by the South West 24 worker they will contact the consumer by telephone and then they will triage them at this time. One concern is the probability of the client not having a contact number or home phone or even a home. If contact can be made the South West 24 worker will decide who the person should be referred to this may well be their GP who referred them in the first place or the South West Mental Health Services in their area. After this referral has taken place an appointment will be made with the nominated service ...this process appears to be lengthy and could take several days for a potentially unwell client to be "seen" by a clinician. A concern for this organisation is the welfare of the client and the possible difficulties they experience during this referral period.

(NGO Service Provider, Western Australia, Submission #45)

Women who are deemed to be an extremely high risk are referred to the Forensic Community Mental Health Service. One case I can cite will demonstrate the extreme difficulties and deficiencies in service delivery in this area. The woman I am referring to has been assessed as an extremely high risk of suicide, and of re-offending. Her offending behaviour is of a nature that constitutes an extremely high risk of harm to others. The Forensic Mental Health Service repeatedly warned me what a high risk this woman is. However, every time I called them in a crisis, there seemed to be some reason (usually lack of available staff) why they could not respond. The case manager actually said to me on several occasions that they just do not have the resources to respond to crises, and that they are not an emergency service. I would be left to negotiate with an extremely unwell and potentially dangerous person, to accompany me to A&E [Accident and Emergency] (and wait 5-6 hours) to undergo an emergency psychiatric assessment. With no statutory power, there was nothing I could do if she refused to come. The Forensic Team eventually transferred this client to a different team, on the basis that they were not adequately resourced to respond to this client's level of need. I have grave doubts about any community forensic mental health team (or any community mental health team for that matter!) that says they are not a crisis service.

(Social Worker, Western Australia, Submission #15)

Issues of Bunbury Mental Health Services:

•  It is reported that there is no clear policy on how to prioritise who is seen and who is not seen, currently emergency referrals are the only ones being responded to. Individuals and other agencies are describing extreme difficulty in successfully referring new patients.

(Advocate, Western Australia , Submission #2)

...shortage of beds. When a patient is on a Community Treatment Order which has to be revoked because the patient has become unwell and in the absence of any intermediary facility requires hospitalisation. There is again often no bed available for them ...

(Carer Advocate, Western Australia, Submission #339)

Involuntary patients continue to be transferred to Perth, sometimes despite attending as a voluntary patient. There is some suggestion of a black list of people who will always be refused entry to Bunbury Hospital. If this is case, should there not be a process of appeal against what may in fact be nothing more than a punitive measure.

(Advocate, Western Australia, Submission #2)
6.5.11.1.2 Police response is the only response - police are the de facto mental health service

Due to the inability of consumers and carers to access mental health services during times of crisis, police were called as a last resort as they were available to respond 24 hours a day 7 days a week. However, the mental health service is also meant to be available and provide crisis intervention services on a 24 hour basis, 7 days per week (Standard 11.1.4). Included in the notes to this Standard are crisis teams, extended hours teams and 'cooperative arrangements with other appropriately skilled service providers and community agencies including General Practitioners, private psychiatrists, general hospitals'. The following comments indicate that this level of support is not currently available as the mental health service is directing people to call the police:

As a carer of a daughter with a mental illness my husband and I were forced to call police for help because we couldn't get any other response. The police were wonderful but after an 8 hour wait to be assessed the local hospital said they couldn't deal with her and she was sent to Perth to a secure ward. She was very quickly discharged and now we are dealing with the same situation again. Where do we go for help when there is no help?

(Carer, Western Australia, Bunbury Forum #10)

I have a friend in trouble who threatened to kill her daughter. I phoned SouthWest 24 and they told me to phone the police. The police were fantastic ...

(Friend, Western Australia, Bunbury Forum #3)

(In response to the questions, "How do the Police behave? Are they adequately trained? Do they know what they are doing?") ...Yes but they don't always give it a high priority therefore things can get out of hand in the time it takes for them to respond. They are sometime short staffed. We need to have more trained people on the ground.

(Carer, Family member, Western Australia, Geraldton Forum #51)

Carers in some of these remote rural areas have reported having a crisis at midnight on a Friday. When attempting to contact SW24 they have told me the service has advised them that their problem will be forwarded to the clinicians who they know will not be in the office until the following Tuesday. When they explain this they are often asked to take the person they are concerned about to the nearest health facility which will handle psychiatric emergencies ...Should this not be possible their alternative is to contact the local police, who are for most at least fifty kilometres away and usually only have one officer on duty, who then has to choose between leaving a town with out a service for what may turn out to be a ten hour round trip to Perth or advise the family they can not attend and this leaves them to fend for themselves.

(NGO Service Provider, Western Australia, Submission #45)
6.5.11.1.3 Lack of access to care - "right to get care, not be arrested"

An inability to access services when needed in some instances resulted in consumers entering the criminal justice system as a result of their deteriorating and untreated mental illness. The failure of services to respond and intervene in these instances also had the regrettable outcome of the right to safety of the community being infringed and in the extreme case, death of a person:

My brother suffers from bipolar disorder and my mother and I came here for him for 23 years. But I would like to comment on the fact that people with a mental illness are being arrested because often it's the only way they can get any help. They have a right to get care, not be arrested. We've got to get access to early intervention programs but it doesn't happen - now my brother is in the court system, not because he's bad but because he's got a mental illness.

(Carer, Sister, Western Australia, Bunbury Forum #24)

My brother also has an intellectual disability as well as bipolar disorder ... Yes my brother has been convicted of crimes. I have had to represent him in court. He would never have ended up in those terrible predicaments if he had adequate facilities and care to live independently within the community.

(Carer, Sister, Western Australia, Submission #101)

He was charged with wilful murder in Nov 2000. He is now in prison facing a 20 year prison sentence. In 1999 ...[h]e was delusional and needed help. I spent four days ringing the crisis centre in Maylands Mental Health (PET) regularly and each time had to tell the full story - they wouldn't listen to me and wouldn't do anything. I rang the police nothing was done. They wouldn't do anything. After three and a half years in Graylands he is now better than he has ever been. He is now in Hakea prison. The help I got was none. For a dangerous situation there was no help available for me or my son.

(Carer, Father, Western Australia, Geraldton Forum #49)
6.5.11.1.4 Access denied due to past forensic status

Reports were also received that consumers were discriminated against on the basis of past forensic status. According to Standard 11.1.1 such discrimination by the MHS is not to occur and such consumers are not to be diverted to other services. The Standard states that the MHS ensures equality in the delivery of treatment and support regardless of past forensic status. However, this was not the case for some people:

I understand that an application of referral to the South Guilford Centre for rehabilitation has been declined due to his conviction ...My brother is both Bipolar and has an intellectual disability. I believe his convictions are a direct result of the lack of available services to him whilst he tries to live independently in the community. Up until now we have always had to jump hurdles in order that the Mental Health Services and Disability Services work together as a team ...The very idea that my brother has been refused admission to attend the South Guilford Centre for rehabilitation is discriminatory to say the least. What is the purpose of rehabilitation I believe that my brother presents a low risk to this group and deserves the chance to be considered on his merits not on what he has been convicted of ...I believe there is a forensic rehabilitation centre that my brother is considered to be "not criminal enough" to be referred there. It seems to me that once again no-one wants to help my brother as he does not fit the criteria for either centres? Surely he deserves the chance to have some rehabilitation? Or should he be left in limbo with out the resources to rehabilitate himself? I believe in timely intervention and prevention, rather than addressing the situation when things have gone horribly wrong ... This group would surely be able to help him live it a little better by developing his skills through a well thought our rehabilitation programme that is ongoing.

(Carer, Sister, Western Australia, Submission #101)
6.5.11.1.5 Access denied due to history of sexual abuse

One submission detailed discrimination on basis of past sexual abuse and was denied 'equality in the delivery of treatment and support' (Standard 11.1.1):

...accessed the Mental Health Services for about three sessions. This was long enough for her to engage with the worker and to feel as though she would be getting a service. However, as soon as she mentioned a past history of sexual abuse she was referred to SARC [Sexual Assault Resource Centre]...I also feel that Mental Health issues and sexual abuse issues often overlap and that the clients should be told they have a choice about which service they access. In this case she was denied further access to Mental Health services.

(Clinician, Western Australia, Submission #333)
6.5.11.1.6 No access to any MHS - regional location

In Esperance we have had no psychiatrist for five months. If consumers need acute care they have to be taken to a GP and then tranquilised and strapped to stretcher to be transported to Perth.

(Consumer, Western Australia, West Perth Forum #45)

For Western Australia, the vast geographical area poses serious challenges to the planning and delivery of services that are convenient and local and linked to the consumer's nominated primary care provider (Standards 11.1.3) and where effective and equitable access to services is ensured for each person in the defined community (Standard 11.1.5). However, submissions repeatedly reported cuts to services which were already operating at minimal levels in various areas rather than service enhancement.

Lack of access to services appears to leave consumers and carers with no choices but to allow the illness to deteriorate, or for the consumer to be transported while sedated or with armed escort to an appropriate service. Such options placed great burdens on both consumers and carers as often, services are a great distance from the consumer's home.

This generally means that a crisis has to eventuate before services can be accessed and the consumer requires hospitalisation, due to the shortage of acute care beds in WA. The bed shortage also generally results in the consumer being discharged early. For consumers in rural and regional areas in particular, problems with follow-up and support then ensue. In the event of a need for readmission, this is at enormous cost to both consumers and carers, and ultimately on health resources:

Consumers are driven in the back of paddy wagons - three day trips - from Kununurra to Perth. The artificial geographic boundaries create huge problems for people needing care.

(Carer, Western Australia, West Perth Forum #43)

How much does it cost to transport a patient by Ambulance to Perth? There are no doctors available here in Bunbury on nights or weekends so they send us to Perth! What have we got for a mental health system? Nothing, absolutely nothing!

(Consumer, Western Australia, Bunbury Forum #1)

There is a perception in the community and by the community mental health team that patients from the South West are discharged prematurely and without follow-up being arranged.

(Nurse, Western Australia, Submission #55)

Only recently in July, Carers at a Carer Advocacy & Issues Forum in Bunbury met and expressed their frustration regarding the sudden closure of mental health services in their community. Specific concerns regarding the closure of services include: Issues surrounding the transfer of patients to Perth including financial costs to carers for transport, accommodation and lost income.

(Carers WA, Western Australia, Submission #277)

There is a concern that many parents in the South West of WA are placed under more pressure (financial and logistical) because there are no specialists in this area to assist children who are diagnosed with ADD/ADHD and they need to travel to Perth.

(Anonymous, Western Australia, Submission #145)

National Mental Health Plan 2003-2008 ... Page 10 - "All people in need of mental health care should have access to timely and effective services, irrespective of where they live". This is not even a reality for people living in Perth - god knows what it is like in rural areas ...

(Carer Advocate, Western Australia, Submission #339)

Surely it would be better to keep mental health people here in this town where they are close to their family and support. This doesn't happen because there is not the facility for their care therefore they are sectioned and sent off.

(Anonymous, Western Australia, Geraldton Forum #96)
6.5.11.1.7 Lack of access to care - regional area - transportation issues

As mentioned above, when there are no services in an area to access, consumers either have to organise their own care, or in the event of a crisis or large distances, they must be transported. Often this required the involvement of police or the Royal Flying Doctor Service and the requirement for chemical and/or mechanical restraint. Such restraint was in particular seen as excessive by one general practitioner and both potentially a health risk for consumers, and a violation of a person's dignity and right to freedom.

There are many ways in which the consumer's rights were violated when care was not readily available. Problems with the current telephone access plan, common across Western Australia, are illustrated in the following quotes:

There is an agreement between the police and the local mental health service. If patients are sectioned under the Mental Health Act the police are not allowed to transport more than 250 kilometres. Therefore the only option here is to take patients to Perth by the Royal Flying Doctor Service, the result being that the patient has to be extremely sedated. There is a need for them to be sedated to stop them from doing harm to themselves or others. I don't have a problem with that - but what I can't cope with is when I am asked to give a higher level of medication in order to transport this patient by air ...Why should I or other doctors - contractually obligated to give people this medication - be required to over sedate patients just for convenience of transport?

(GP, Western Australia, Geraldton Forum #53)

I can support what the police office said earlier about people who have been transported by the police to Graylands hospital often beating the police back to Bunbury!

(Carer, Mother, Western Australia, Bunbury Forum #22)

...We were then told our son wasn't welcome to stay here in Bunbury hospital because of a previous experience they had with him. I told them I would take him to Graylands in my own car but I just needed to go home and get some things first. But then they sedated him even though I told them I would transport him to Graylands ...20 hours later after being in a drug induced state in Graylands he was discharged, the next morning, without any explanation to him or to us.

(Carer, Mother, Western Australia, Bunbury Forum #22)
6.5.11.1.8 Phone service is the only contact with MHS service

Many problems have been encountered with this service. The absence of other supporting services left consumers and carers feeling helpless and without any access to any real mental health service.

When we talk about the South West 24 emergency telephone services and how it has now become the single point of entry for those seeking clinical assistance by the South West Mental Health Services I would like to point out for those living in rural areas there is often no landline telephone connections and mobile phones simply will not work. Further this service is for those in the South West and does not cover carers or consumers living in the Lower Great Southern, therefore for many there is no access to this service or anything similar.

(NGO Service Provider, Western Australia, Submission #45)

Carers in some of these remote rural areas have reported having a crisis at midnight on a Friday. When attempting to contact SW24 they have told me the service has advised them that their problem will be forwarded to the clinicians who they know will not be in the office until the following Tuesday. When they explain this they are often asked to take the person they are concerned about to the nearest health facility which will handle psychiatric emergencies. Again for many this may be Bunbury which is located over two hundred kilometres away, further should they be able to get to Bunbury they are often told they can not be seen and are sent onto Perth a further two hundred and forty kilometres. Should this not be possible their alternative is to contact the local police, who are for most at least fifty kilometres away and usually only have one officer on duty, who then has to choose between leaving a town with out a service for what may turn out to be a ten hour round trip to Perth or advise the family they can not attend and this leaves them to fend for themselves. Although on the surface a 24 hour call services appears to be an effective means of offering support to people it is in fact only able to offer information which in most cases the person is already aware of, but it has very limited if not non existent ability to offer "hands on" or "face to face" practical assistance.

(NGO Service Provider, Western Australia, Submission #45)

I want to comment on SouthWest 24 (helpline) - I am a parent carer of a child with a mental illness. For people like me in Bunbury, SouthWest 24 is now our only form of contact with a mental health service unless we take our kids to the emergency department. SouthWest24 is now acting as a triage. We need to be able to access direct mental health care in our community.

(Carer, Parent, Western Australia, Bunbury Forum #5)

South West 24 was often mentioned at the conference. In my opinion this could be a valuable service if it was being used to facilitate an already functional service. This service is attracting a lot of funding approx. $450,000 in the first 8 months, and the core services of mental health providing face-to-face service is being neglected. It further over-burdens the emergency department as it often refers clients to that department and there are little or no mental health services provided there.

(Nurse, Western Australia, Submission #55)

I have also used the Rural link number a number of times after hours and have found the immediate follow up op be excellent. I have also found, however, that the Child and Adolescent Mental Health Service in Geraldton has not been in a position to provide the appropriate follow up and support.

(Clinician, Western Australia, Submission #333)

Issues of Bunbury Mental Health Services:

•  Clinicians who are not currently engaging with their patients are in some cases telling patients to phone if they require support. This is clearly not acceptable, one patient described this a being "effectively told to piss off", there is also the issue that clinicians can only be reached on one phone number and assuming that one is well enough to phone one soon would have one's staying power tested when trying to make contact using the single line that is available. This line is often diverted to South West 24 call centre.

•  South West 24 continues to be an issue from various points including the inappropriateness of response, being unavailable and having calls queued up, on one occasion a consumer was told that the answering service was off-shore and they could not help.

•  Another problem is there is no external review process of the service provided by SW24. This seems strange for an allegedly pilot program.

(Advocate, Western Australia , Submission #2)

...Southwest 24 is a service contracted to [Z] and the call centre is in Perth. I have been told that the overflow calls go to Sydney. Some people report good experiences with this service, and some report being unable to access it. The 1800 number is not free to many consumers and this also causes problems.

(Anonymous, Western Australia, Submission #22)
6.5.11.1.9 Access denied for people with dual diagnosis - mental illness and intellectual disability

Standard 11.1.1 states: 'The MHS ensures equality in the delivery of treatment and support regardless of consumer's age ...physical or other disability' and Standard 1.1.5 states 'the MHS ensures effective equitable access to services for each person in the defined community'. Included in the notes to Standard 11.1.5 is 'attention is paid to the needs of Aboriginal and Torres Strait Islander and non-English speaking backgrounds as well as ...disability'. However, reports made at the Bunbury forum indicate that access to mental health services is being denied on the basis of intellectual disability:

I'm a paid carer for people with an intellectual disability. These people are denied access to the mental health ward. Is there a policy? No, we've just been told that they should go to disability services.

(Paid Carer, Western Australia, Bunbury Forum # 2)

I just want to say that there seems to be a real gap in services for people with both mental health and intellectual disabilities.

(Anonymous, Western Australia, Bunbury Forum #4)
6.5.11.1.10 Lack of access to treatment and support services for people diagnosed with personality disorders

Concerns were raised about the lack of treatment and support services for people diagnosed with personality disorder and that problems associated with the disorder are not being recognised or acknowledged by some clinicians and services. Evidence was presented indicating that treatment programs are available in other States but not in Western Australia and that lobbying for these has not resulted in these therapies being made available. The devastating consequences of services failing to provide adequate treatment and support for people with Borderline Personality Disorders were recounted by one consumer:

Currently if a client in Parent Link presents with a personality disorder, where do you go??

(Anonymous, Western Australia, Geraldton Forum #82)

At the Department of Community Development, for many years field workers have commented that there are no links or feedback with mental health services. When they take people along with personality disorders and they say no they don't deal with them as they don't fit and we have had problems in that area, they are sent back to our workers.

(Department of Community Development worker, Western Australia, Geraldton Forum #85)

My primary concerns in relation to mental health, are the extremely high rates of incarcerated women (and men) with both diagnosed and undiagnosed mental illness, and furthermore the treatment they receive from health services whilst in prison. There are also serious issues relating to treatment post release from community mental health services ... I know I do not have to outline the issues related to dual diagnosis, which this client group exemplify. Particular problems also arise for this client group when a Borderline Personality diagnosis is given, which is very often.

(Service provider, Western Australia, Submission #14)

...a woman I was trying to link into mental health services after she was released from prison. Due to her primary diagnosis of personality disorder, it was impossible to get any mental health service to accept her care, even though it was a condition of her parole that she receive psychiatric treatment. When we tried to get prison medical staff to refer her to appropriate services, and argued that she was prescribed anti- psychotic medication in prison, we received the above quoted response, that so are 95% of the women there. It is an ongoing problem that women leaving prison are not eligible for mental health services, due to a primary diagnosis of PD.

(Social Worker, Western Australia Submission #15)
6.5.11.1.11 Difficulty accessing psychiatrists and psychologists

A report was also received regarding the lack of psychiatrists and psychologists to meet the needs of consumers in rural and remote areas. Concern was expressed about the infrequency of visits by specialists and long waiting lists for appointments:

Availability of psychiatrists is a problem. I suffered from depression in February / March this year. I rang my psychiatrist's office in Perth and he wasn't coming to Geraldton before October - there would be a 3 month wait to see someone in Geraldton. I could get PATS [Patient Assisted Travel Scheme] - I was given the yellow form. I took the form to my GP who wouldn't sign the form because she said I didn't need to see the psychiatrist. So I went anyway and paid for it myself. In the mean time I was asked to have an appointment with the local psychologist in town and I am still waiting for the appointment. This happens all the time.

(Consumer, Western Australia, Geraldton Forum #66)

From time to time difficulty is experienced across the region in gaining access to tertiary level support facilities in Perth. It is appreciated that the metropolitan area is struggling with its own difficulties. However, the flow-on effects of this can be quite challenging in rural areas where resource is even more limited ...

(extract from a letter to the Office of the Chief Psychiatrist) (Clinician, Western Australia, Submission #24)

6.5.11.2 Entry

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

Under this Standard, submissions and presentations indicate concerns about:

  • qualified mental health professionals not available to assist with entry;
  • problems when phone is the only entry point to the system; and
  • problems with entry via emergency departments.
6.5.11.2.1 Qualified mental health professionals not available to assist with entry

As acknowledged, the vast geographical area of Western Australia does pose challenges to the delivery of services. However, problems with access and entry when at a crisis point are further compounded when an appropriately qualified and experienced mental health professional is not 'available at all times to assist consumers to enter into mental health care' (Standard 11.2.6):

One day my son came to us for help. He said he wasn't feeling well and we tried all day to get a bed for him in the hospital here. As a last resort my lad presented himself to a GP and he was later interviewed by a person who we thought was a mental health professional and we later realised it wasn't. Then a security guard came and informed us he would be sent to Graylands Hospital in Perth. We were then told our son wasn't welcome to stay here in Bunbury hospital because of a previous experience they had with him. I told them I would take him to Graylands in my own car but I just needed to go home and get some things first. But then they sedated him even though I told them I would transport him to Graylands ...20 hours later after being in a drug induced state in Graylands he was discharged (the next morning) without any explanation to him or to us.

(Carer, Mother, Western Australia, Bunbury Forum #22)
6.5.11.2.2 Problems when phone is the only entry point to the system

As indicated by one GP, when phone access became the only method to access services in regional areas, problems experienced by consumers and carers were exacerbated:

SouthWest 24 has been around for quite a while as a private company - it used to work reasonably well but the problems occurred earlier this year when it became the single point of entry into the system!

(GP, Western Australia, Bunbury Forum #19)

It appears here that Standard 11.2.3 has been misinterpreted. The Standard states that: 'The MHS can be entered at multiple sites' (e.g. on-call, intake, assessment and triage in emergency department, psychiatric unit, police service, private psychiatrist, school etc.)... 'coordinated through a single entry process'.

6.5.11.2.3 Problem with entry via emergency departments

Problems were also reported with access and entry via emergency departments described as being inappropriate due to long wait times and these areas being crowded and generally inappropriate environments for people with a mental illness:

I am speaking on behalf of a man who took his suicidal wife to a mental health service for care. Her assessment by the service was very poor. He felt there was a resistance from the service to treat her but I don't know why - the woman became increasingly unwell and was eventually admitted through the emergency department process, not through the mental health service. This access through emergency departments means that people are being held in situations which are completely inappropriate.

(Carer and Advocate, Western Australia, West Perth Forum #32)

Carers report that the current funding and provision of mental health care in WA is clearly inadequate to meet the level of need. This is demonstrated by: people presenting at hospital emergency departments requiring treatment for mental illness waiting in corridors as beds are not available in psychiatric hospitals ...

(Carers WA, Western Australia, Submission #277)

6.5.11.3 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:

  • no notification of arrival for assessment and use of force;
  • problems with staff workload and management of work; and
  • concerns about the quality of the assessment and review process.

Linked with problems of access and entry and limited services are reported problems with assessment and review. Submissions detailed difficulty organising assessments, poor assessments and problems with assessment and review resulting in early discharge. The problem of early discharge from metropolitan hospitals for consumers living in rural and regional areas where follow up services and support are limited or non existent left carers feeling helpless, as described above. Further problems with regional services are reported below:

I am a solicitor recently come to Geraldton and I find there is a poor nexus with mental health services. Local mental health services will not supply letters to the legal system therefore people are being charged instead of treated. There was one instance where a person was heard by two JPs [Justice of the Peace] who could not order an assessment. This was referred to a Magistrate in Carnarvon. I am not aware of any assessments being brought on in Geraldton. I am concerned because it then goes through to what?

(Solicitor, Western Australia, Geraldton Forum #57)

Recently one of these longer-term residents became unwell. He is a very high maintenance resident who needs considerable staff time to assist him to live in the Hostel. The Hostel requested and immediate assessment of this gentleman by clinical services. He was assessed by a doctor and the Hostel was told it did such a good job in managing this gentleman's mental health, that there was no need for hospitalisation, just an increase in medication. At that time there were no acute beds available in any case. The man's condition deteriorated and he was threatening both staff and residents and it was finally decided, after much convincing on the part of a number of staff it would be appropriate to admit him to hospital.

(St Bartholomew's House Inc, Western Australia, Submission #37)
6.5.11.3.1 No notification of arrival for assessment and use of force

Of particular concern was a reported incident of an assessment with no notification at a consumer's place of residence with police accompaniment. From this report, it appears that many of the consumer's and his carers' rights were violated. These situations clearly perpetuate problems of stigma and discrimination based on mental illness.

...For some time now he has been treated for his condition by injection at home. On Thursday, August 19, 2004 he commented that he thought he felt another episode coming on. My wife then contacted the local mental health office and was advised that it was no longer possible to treat our son as in the past and that we would have to see Dr [Y]. An appointment was made for August 27 2004. We attended this appointment and were told no treatment would be administered until our son was assessed. This we were told might result in our son being placed on community order and admitted to hospital - presumably Graylands. Because of past experiences with Graylands our son has no intention of voluntarily returning there. My wife and I therefore felt that it would be a betrayal of his trust in us, his parents, to agree to this so we decided to seek other medical advice. Dr [Y] telephoned later that day to say that he was coming to see our son. He was advised this was not possible because our son was asleep and we did not want him disturbed. Sometime before 4pm that same afternoon Dr [Y] together with an assistant and a police vehicle carrying three police officers arrived at our son's house and forced our son, who was ill and asleep at the time, to open his door. Needless to say our son was traumatised by the event. Fortunately my wife noticed the vehicles outside our son's house and we went to investigate. By this time the vehicles were moving off but we were able to speak to the police officers who were less than co-operative and the medical staff, who did not have the common decency to inform us of the visit, told us they were within their rights and that we had no reason to be upset. My contention is that Dr [Y] was not within his rights and by his actions he has caused a mentally ill patient additional needless trauma. My wife spent several hours with my son after the visit trying to calm him down. How could we be expected to show any trust to this doctor again? Any faith in the mental health profession built slowly over the past few years has been destroyed. The actions of Dr [Y] have caused undue stress to my wife and myself.

(Carer, Father, Western Australia, Submission #175)
6.5.11.3.2 Problems with staff workload and management of work

Many submissions wished to acknowledge that failure to deliver quality treatment and support services was not a reflection on the work of individual staff but systemic issues related to workload (Standard 11.3.19), management of work and overall lack of resources that restricted the clinician's ability to deliver quality care. The following quotes highlight this issue:

What I would like to say is that actually we have extremely good mental health people who do the best they possibly can. However, they are over-managed. You ask what happens with mental psychologists however, they are over worked. [Regional Director] says that all is OK.

(GP, Western Australia, Geraldton Forum #62)

CWMH individuals do well and we have a very good psychologist but they are overwhelmed and over managed. As GPs we cannot refer to anyone but "the team" - they decide. They have one day deciding who will take which patient - i.e. they use 1/5 of their working time - it is not an efficient use of their time. I'm trying to help people seek help - what will they get?

(GP, Western Australia, Geraldton Forum #62)

...Nursing and Security Staff at the Bunbury Regional Hospital were extremely supportive and helpful during this most distressful time. These staff members should be commended for their moral and compassionate support to us, when they were clearly under a lot of strain. This, we believe, is mainly contributable by the high work loads that exist for these staff. This is yet another issue which needs to be addressed.

(Carers, Western Australia, Submission #177)

Doctors and nursing staff are struggling with ever mounting burdens of care, while working with continually decreasing resources in Graylands Hospital and the mental health clinics ... Every time we speak to nursing staff when visiting our son in Graylands Hospital, the staff speak of their exhaustion and stress.

(Carers, Parents, Western Australia, Submission #76)

The medical on call roster is often left with blanks for the Consultant Psychiatrist, which is unacceptable in an authorised unit. At one time, a Consultant Psychiatrist was on the on-call roster from Perth and when required to attend the Unit for patients received on a Form 1, did not attend. The form often lapsed, the patient wasn't seen, and at times Form 1 is written over again to extend the time.

(Clinician, Western Australia, Submission #55)
6.5.11.3.3 Concerns about the quality of the assessment and review process

Concern was expressed regarding the quality of assessment procedures. Standard 11.3.1 states: 'Assessments are conducted by appropriately qualified and experienced mental health professionals' and Standard 11.3.5 states: 'The assessment process is comprehensive and, with the consumer's informed consent, includes the consumer's carers (including children), other service providers and other people nominated by the consumer'. Standard 11.3.6 further states: 'The assessment is conducted using accepted methods and tools'. Concerns were raised regarding delays in reviews required with certain medications, delays in reviews of Community Treatment Orders, non-comprehensive assessment and diagnosis procedures, concerns about the qualifications of staff conducting assessments, and consumers not being heard:

Issues of Bunbury Mental Health Services:

•  Access to psychiatrist as noted previously is limited due to limitations on rooms that can be used. It is coming to light that Clozapine reviews by psychiatrist are not happening, which according to protocol should be three monthly. The monthly medical officer reviews are continuing at this point, but the office utilised for this is under threat by the expansion of the community staff in the inpatient unit. Also monthly CTO [Community Treatment Order] reviews are not happening. This is the state of play just now however one of the psychiatrists has resigned and will leave in 3 / 4 weeks, what happens then to access to a psychiatrist?

(Advocate, Western Australia , Submission #2)

When our son did finally get to see Dr [Z], within one hour of entering the clinic he was pronounced miraculously cured, his diagnosis was changed to a behavioural disorder, he was given a three month supply of anti psychotic medication, told to go for a C.T. [Computed Tomography] scan and advised that he would be managed by his local GP from there. This despite the fact his local GP had absolutely no experience with him. However after spending seven years dragging our son to a clinic and dealing with his frequent episodes unassisted, to be told he has no condition other than a behavioural problem, lowers the science of psychiatry into the realm of the black arts ... At the time of writing this letter we have still not been able to get our son to the C.T. scan clinic he is so agitated and not well. I rang Armadale Hospital and asked them what to do (they said they would speak to Dr [Z]) this was four weeks ago no one rang back.

(Carer, Mother, Western Australia, Submission #13)

Some Emergency Department medical practitioners rely on Level 2 nursing staff for mental health and psychiatric assessments. To the best of my knowledge this is not the case for medical or surgical emergency presentations. In my opinion, credentialing may need to be reviewed in the case of any medical practitioner unable to undertake a bio-psycho-social assessment including mental state examination, risk assessment and management plan development. All of these issues, really, raise important questions in regard to strong clinical governance ...

(extract from a letter to the Office of the Chief Psychiatrist) (Clinician, Western Australia, Submission #24)

Problems consumers have with the referral process to mental health services for assessment by and Authorised Mental Health Practitioner.

•  Many consumers report the experience of not being given any credibility to speak on their own behalf, having previous history given too much weight against what they may have to say on their own behalf, and inordinate weight is placed on the information provided by others relating to their situation.

•  Another significant complaint from consumers is that of being medicated forcibly before being given an opportunity to speak on their own behalf. The agitated presentation of a person brought in for assessment can be a product of the traumatising experience of police transportation and not exclusively the manifestations of illness ...

(Health Consumers' Council WA , Western Australia , Submission #29)

[Supporting mothers with mental illness] Recommendations: use simple and non-threatening assessment tools to assist in identifying mother's parenting concerns at initial contact. Early assistance will prevent crises.

(Health Consumers' Council WA, Western Australia, Submission #29)

6.5.11.4 Treatment and support

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

Under this Standard, submissions and presentations indicate concerns about:

  • resistance to involve consumers and carers in the planning of treatment and care;
  • lack of services for people with dual diagnosis - intellectual disability;
  • lack of services for consumers with dual diagnosis - drug and alcohol;
  • lack of services for consumers with hearing impairment;
  • no child and adolescent service to access;
  • lack of treatment and support services for consumers who are elderly and homeless;
  • lack of treatment and support services for consumers who are homeless;
  • lack of treatment and support services for people with eating disorders;
  • lack of services in rural areas;
  • lack of treatment and support services for Indigenous consumers and their families living in remote communities; and
  • lack of appropriate treatment and support services for consumers in the criminal justice system.

Despite the successes in making the changes outlined in the chapter on 'Changes Made' there are still unacceptable practices to be addressed. The outcomes though commendable do not represent 'best practice' or indeed in many cases even 'good practice'.

(Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

The above statement captures the essence expressed in many submissions about the quality of treatment offered by mental health services. Indeed, the above indicates that treatment and support offered did not 'reflect best available evidence and emphasise positive outcomes for consumers' (Standard 11.4.1). The inability of consumers to access services particularly at onset of illness and during the recovery phase (Standard 11.4.4) indicates that a 'focus on positive outcomes' is not a serious aim of the WA Government:

There has been a reduction in inpatient beds and an increase in people living with mental illnesses being expected to live in the community with little or no support.

(St Bartholomew's House Inc, Western Australia, Submission #37)

Additionally, a lack of resources and community services often results in the requirement for hospitalisation, but a lack of hospital beds complicates access to services even at this point:

Another big problem is around the number of involuntary beds we have in Bunbury Hospital. Once before we had these beds, then they were "taken away", now we have them again but the number is completely inadequate to our needs in this community.

(GP, Western Australia, Bunbury Forum #19)
6.5.11.4.1 Resistance to involve consumers and carers in the planning of treatment and care

Standard 11.4.9 states: '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.' As the following quote suggests, with respect to the development of individual care plans, there is a significant mismatch between the rhetoric and the reality:

The survey showed that nursing care plans were not formulated with the patients or carers, hardly ever consulted by nurses in delivering care, seldom used in shift to shift hand over and rarely, if ever, consulted by medical staff or other disciplines (p. 16). The system is inconsistent with the National Mental Health Policy (1992) which states that consumers have a right to participate in decisions regarding their treatment, care and rehabilitation.

(Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

Concern was also expressed that consumers, and their carers, are not involved in decisions about their treatment and care implies that some consumers are denied their right to have information provided about their illness, progress or to be involved in any treatment choices available to them:

Patient meetings were originally planned for and held on a weekly basis. However the schedules of the meetings became increasingly erratic. As a result of failure to hold meetings, patients were not given the opportunity to discuss issues and present their concerns to staff. Consumer representatives were also denied the opportunity of speaking directly to patients.

(Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

Similarly for carers, involvement at this stage is critical if the best possible outcome is to be achieved for the consumer and the carer is to be empowered with knowledge to assist with the delivery of care:

My other concern is for the carers they are told not to get involved but there's no one else to get involved. If the service doesn't want to involve carers then who do they think will provide the care once someone is discharged from a hospital? Who else is there?

(GP, Western Australia, Bunbury Forum #19)

Carers WA and the Mental Health Carers Issues Network recently conducted research into the needs and issues of carers of people with mental illness ... What three things would you change about mental health services? This question received the greatest response. The most important change that carers want from mental health services is respect for and involvement of carers (21%). They want more recognition of and respect for carer knowledge and their role; to be heard and be believed; psychiatrists to take more notice of their knowledge and experiences; to be involved in their family member's/friend's treatment program; a team approach to treatment; a holistic treatment program; greater respect for people with mental illness; and greater monitoring of people with mental illness. (author's emphasis) (McKeague B, 2003. Worried, Tired & Alone - A report of Mental Health Carers' Issues in WA. Briefing Paper)

(Carers WA, Western Australia, Submission #277)
6.5.11.4.2 Lack of services for people with dual diagnosis - Intellectual disability

Standard 11.4.7 states: 'The MHS ensures access to a comprehensive range of services which are, wherever possible, specialised in regard to dual diagnosis, other disability'. In the notes to this Standard is 'collaborative treatment with ...disability services'. One carer detailed the problems she had in organising treatment and support for her brother with Bipolar Disorder and intellectual disability, even after suicide attempts. She believes the inability to access appropriate treatment and support services for her brother resulted in his deteriorating mental health and eventual entry into the criminal justice system:

My brother is both Bipolar and has an intellectual disability. I believe his convictions are a direct result of the lack of available services to him whilst he tries to live independently in the community. Up until now we have always had to jump hurdles in order that the Mental Health Services and Disability Services work together as a team.

(Carer, Sister, Western Australia, Submission #101)

There seems to be no where to go if you are at suicidal risk. My brother's wounds are often treated and he is discharged from hospital with little or no regard to his mental health. My brother also has an intellectual disability as well as bipolar disorder. His suicidal attempts are labelled behavioural related to his IQ and not his mental health. DSC [Disability Services Commission] want to handball him to Mental Health Services and visa versa.

(Carer, Sister, Western Australia, Submission #101)
6.5.11.4.3 Lack of services for consumers with dual diagnosis - drug and alcohol

Standard 11.4.7 states: 'The MHS ensures access to a comprehensive range of services which are, wherever possible, specialised in regard to dual diagnosis'. The notes to this Standard include 'dual case management with alcohol and other drug services'. Concern was expressed that there is an insufficient number of services to provide the appropriate treatment and support for consumers with complex needs and hence these consumers are either kept in a locked ward or discharged and become homeless or enter the criminal justice system:

My son is 19 and he has chronic schizophrenia and a drug abuse problem - he's been in the locked ward at Graylands for quite a while and I'm glad he's been locked up for that long because he can't cope outside the hospital. He lives with me and I worry about what will happen to him if he is released - he can't be accommodated anywhere and this is a human rights issue - there's unreasonable pressure on the family to provide care for really sick people like my son ...My son can't even get supported accommodation. He was assessed and because he said he wouldn't give up his cannabis - he can't lie - they won't accept him.

(Carer, Mother, Western Australia, Perth Forum #31)

Often the best way to deal with drug and alcohol problems is through a team approach. Sometimes we get very good support from individuals in the mental health teams but now that's become increasingly difficult - almost impossible.

(Manager of drug service, Western Australia, Bunbury Forum #23)

Drug and Alcohol is like a draw bridge, you only let in the ones you want to let in and only let out what you want to let out. They're keeping out those with drug and alcohol problems, which most of them have.

(GP, Western Australia, Geraldton Forum #62)

Where are the services for people suffering form a dual diagnosis (mental patients who use drugs / alcohol)? The drug services want mental health to assist these people. Mental health want the courts and prison system to deal with these people. And the Courts consider the issue to rest with Mental Health. Inevitably these people end up in Prison, which seems to be the dumping ground for anyone with mental health issues and obviously this is not an appropriate place for them. There are not enough beds for mental health patients which means that the few beds available go to the "deserving few" - whatever that means, presumably it means those people who do not have a drug/alcohol problem.

(Anonymous, Western Australia, Submission #145)

I recommend the Western Australian Police Service, Department of Health and Department of Community Development ensure there are appropriate facilities to care for intoxicated persons in need of protection from themselves which need to be adequately: (a) provided for, and (b) funded if the Protective Custody Act 2000 is to achieve in practice the objectives set out in theory. (excerpt from Coroners Report, 2004)

(St Bartholomew's House Inc, Western Australia, Submission #37)
6.5.11.4.4 Lack of services for consumers with hearing impairment

Standard 11.4.7 ensures access to a comprehensive range of treatment and support services which are, wherever possible, specialised in regard to dual diagnosis and other disability. Concern was expressed that consumers who have a hearing impairment were experiencing excessive difficulty in accessing treatment and support services to meet their needs. Also, Standard 11 (Access) states that 'The MHS ensures equality in the delivery of treatment and support regardless of ...physical or other disability'.

The needs of people in mental health who are hard of hearing are often not met. If you already have one disability and then have a mental illness on top of that it's doubly hard to get help.

(Consumer, Western Australia, Perth Forum #37)
6.5.11.4.5 No child and adolescent service to access

Consumers, carers and clinicians expressed concern at the paucity of services for children and adolescents. 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 particular, concern was expressed that the few services that did exist are rapidly diminishing, waiting lists are becoming longer and children are being inappropriately admitted to adult inpatients units.

The psychiatrist that was here before was great with feedback to other services and families - now the situation is hopeless. There are 2 of us (school counsellors) covering 8,000 people in this area. There is no child psychiatrist in the area and the service knew for about 12 months that he was leaving. Nothing has been done that I can see to replace him.

(School counsellor, Western Australia, Bunbury Forum #8)

I want to talk about the problems in getting services to children and youth - I can't understand why it's such a problem ...perhaps there is no staff.

(Anonymous, Western Australia, Bunbury Forum #18)

There's absolutely no service at all for child and youth mental health except through private paediatricians.

(GP, Western Australia, Bunbury Forum #19)

[I]n Meekatharra the CAMHS [Child and Adolescent Mental Health Service] worker who visited once every two months was always booked out with appointments. Therefore, it would appear that the need indicated that the amount of times she visited should have been increased. Instead these visits are no longer taking place.

(Clinician, Western Australia, Submission #333)

...I have noted the following issues with the Mental Health Services in both Carnarvon and Geraldton; The Child and Adolescent Mental Health service in both Geraldton and Carnarvon has not been running for substantial periods of time over the past three years. This has left many children and adolescents at high risk of suicide. In Carnarvon a number of aboriginal adolescents have committed suicide.

(Clinician, Western Australia, Submission #333)

Most recently I have made referrals to the CAMHS [Child and Adolescent Mental Health Service] service in Geraldton ...I feel frustrated that we would leave a suicidal 7 year old without the support of a counselling service.

(Clinician, Western Australia, Submission #333)

There is a lack of services for students - for example, no doctor on campus and limited counselling opportunities. We've been allocated a disability officer from Perth who attends the campus twice a year but students are not advised. I raised concerns with the Dean, who said service available to high need students only.

(Consumer, Student, Western Australia, Perth Forum #44)

There is a mental health clinician who spoke at the committee about 13 yeat olds in Graylands and the chair of the committee said we are not to release or discuss any of these statistics. But we will not hide this information any longer.

(Consumer, Western Australia, Perth Forum #42)

I have also found, however, that the CAMHS service in Geraldton has not been in a position to provide the appropriate follow up and support.

(Clinician, Western Australia, Submission #333)
6.5.11.4.6 Lack of treatment and support services for consumers who are elderly and homeless

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'. Standard 11.4.6 ensures services which address lifestyle aspects of consumers and the notes to Standard 11.4.7 refer to collaborative treatment with service providers such as aged care. However, concerns were raised with regards to the many difficulties in providing services to consumers who are elderly and homeless and services reported failed attempts in requesting additional support from government to meet the needs of these consumers.

We run a 20 bed aged care and crisis service for people with a mental illness. 18 months ago we had to restrict the number of people with a mental illness coming into our service. I'm not proud of that but we were having too many problems and incidents with those people we identify as the "hard homeless" - they are difficult to care for, they don't pay but where do they go? If you are homeless, with a mental illness you don't get help from anywhere, you don't have a pension because you can't comply with the rules and regulations and most often there's nobody advocating for you. These are the forgotten people! When we've asked government for additional support for these people we've been told we should just move these people on.

(Supported Accommodation and Assistance Program (SAAP) Service Provider,
Western Australia, Perth Forum #33)
6.5.11.4.7 Lack of treatment and support services for consumers who are homeless

Concerns were expressed regarding the lack of treatment and support services for consumers who are homeless. The increasing number of people who are homeless and who have a mental illness and/or mental health problems has also risen with deinstitutionalisation and the subsequent lack of community based treatment and support services to meet the community's needs. Standard 11.4.6 states: 'the MHS ensure access to a comprehensive range of treatment and support services which address physical, social, cultural, emotional, spiritual, gender and lifestyle aspects of the consumer'.

St Bartholomew's House has been providing accommodation and support for people experiencing homelessness for 40 years. Over that time the profile of the people accessing the service has changed. Previously, men were older and most had an alcohol issue. Today the average age for admission in the supported accommodation area is 28 years and men are presenting with complex needs. Many have alcohol and drug issues and/or mental illnesses.

(St Bartholomew's House, Western Australia, Submission #37)

Although St Bartholomew's House continues to try and provide a quality service in supported accommodation (SAAP), the lack of resources, a staff ratio of 1:54, poor education of staff and the numbers of people requiring care limits the capacity to delivering safe quality care.

(St Bartholomew's House, Western Australia, Submission #37)

The SAAP representatives on the committee advised St Bartholomew's House to exclude numbers of mental health clients if they did not meet the new admission criteria developed with a referral process to indicate resident requirements for support and care. St Bartholomew's House elected to have a nominal figure of 10 residents with mental illness accommodated at one time. Unfortunately the House had 10 long-term residents who are unable to live independently so theoretically no more can be admitted. There was a commitment by the mental health clinical services to work with these long term residents to find them more suitable accommodation. 2 ½ years later nothing has been done.

(St Bartholomew's House Inc, Western Australia Submission #37)
6.5.11.4.8 Lack of treatment and support services for people with eating disorders

Carers WA expressed concern about the lack of treatment and support services for people with eating disorders:

One specific area of unmet need that has recently been identified by carers/families is the lack of an information and support network for carers and the lack of treatment and support services for people with eating disorders ...The parents highlighted a number of issues relating to eating disorders including:

1) The lack of an information and support network for the carers, parents and families of people with eating disorders;

2) The lack of treatment and support services for people with eating disorders;

3) The lack of any formal referral pathways for GPs and other health professionals dealing with people with eating disorders;

4) The lack of current information on support services for carers, and treatment and support services for people with eating disorders.

In addition, anecdotal reports from education and health professionals such as school psychologists and school nurses suggest this is a large problem among school students. From a brief investigation of the issues, Carers WA and the Mental Health Carers Issues Network believe this is a serious emerging health and community issue that requires investigation and needs to be addressed.

( Carers WA, Western Australia , Submission #277)
6.5.11.4.9 Lack of services in rural areas

In Western Australia, the vast geographical area poses serious challenges to the planning and delivery of services to meet Standards 11.1.3 ('mental health services are provided in a convenient and local manner and linked to the consumer's nominated primary care provider') and 11.1.5 ('the MHS ensures effective and equitable access to services for each person in the defined community'). For people living in many areas of WA there are no services which are convenient and local. Access to care involves long distances by car, a significant barrier for those who are not so readily mobile or have their own transport.

Carers WA and the Mental Health Carers Issues Network recently conducted research into the needs and issues of carers of people with mental illness ...To the question "What three things would you like to change about mental health services?" carers emphasised that there needs to be greater resources for mental health services especially in rural areas. This included more hospital staff and facilities; additional community nursing; and access to private health care. "In the rural area, the counsellor only comes around once per fortnight. So even if the consumer recognises and accepts the need for help, there's not very much available." (McKeague B, 2003. Worried, Tired & Alone - A report of Mental Health Carers' Issues in WA. Briefing Paper)

(Carers WA, Western Australia, Submission #277)

...services in the lower south west there is a mental health clinic located at Bridgetown which often only opens one or two days per week. This clinic is up to one hundred and twenty kilometres away from some of the towns it services and often further for those living on remote properties. There are two mental health nurses who service this region and they are greatly stretched, making quality contact time impossible.

(NGO Service Provider, Western Australia, Submission #45)

There are no doctors available here in Bunbury on nights or weekends so they send us to Perth!

(Consumer, Western Australia, Bunbury Forum #1)

In Esperance we have had no psychiatrist for 5 months. If consumers need acute care they have to be taken to a GP and then tranquilised and strapped to stretcher to be transported to Perth. I was told when I was suicidal, to drive myself to the city.

(Consumer, Western Australia, Perth Forum #45)

...the general feeling is that we [Esperance] are in a worse position than other cities you visited in this State.

(Consumer Advocate, Western Australia, Submission #35)

All rural and remote regions of WA have the same problems as you found in Bunbury and Busselton to varying degrees. Here in Esperance we do not have the luxury of a Mental Health Hospital wing dedicated for specialised treatment. Some years ago such a unit was built but was used for two or three years only, the difficult of providing 24 hour nursing cover was a problem. This unit is not operational now, due to operational costs and the lack of nurses. I believe these problems could be over come if a business plan was put into place. The alternative is flying people to Perth 750 kms away, very costly and so far from friends or family.

(Consumer Advocate, Western Australia, Submission #35)
6.5.11.4.10 Lack of treatment and support services for Indigenous consumers and their families living in remote communities

Concerns were expressed regarding the paucity of treatment and support services for Indigenous consumers and their families living in remote communities across WA. In particular, the lack of services and vast distances to reach care, lack of follow-up and support, reliance on medication and negative life consequences as a result of lack of access to services were mentioned:

GPs medicate, if the case is too hard they are dealt with by the hospital. We try to keep them within the service and deal with their housing needs work and education.

(Geraldton Regional Aboriginal Medical Service Social Worker, Western Australia, Geraldton Forum #74)

The mental health nurse is on leave at the moment, but we have a child psychologist who is permanent.

(Geraldton Regional Aboriginal Medical Service Social Worker, Western Australia, Geraldton Forum #74)

GRAMS is OK. I tried out the mental health services but it didn't work out for me but Mental Health is not good. I referred a seven year old sexual assault client who was suicidal to Mental Health. There was no response. I then went to Centacare. Mental Health cannot provide the services. Rurallink was positive outcome with that number. Aboriginal Teenagers, however, the only problem with that is they are referred to the Mental Health Service the next day and they just don't like going there.

(Anonymous, Western Australia, Geraldton Forum #78)

I am concerned especially about the long-term effects on the Aboriginal community of the Mental Health Services in town being inadequate. Many reports have shown that Aboriginal males have the highest suicide rate per capita. Surely more need to be done at a local level to stop this epidemic.

(Clinician, Western Australia, Submission #333)

Currently there is no state mental health services 'on site' in the Ngaanyatjarra Lands. These are provided through the mental health service at Kalgoorlie Base Hospital or people are evacuated by air to Perth to inpatient services at Graylands Hospital.

(Anonymous, Northern Territory Submission #271)

As with the Northern Territory and South Australia, clinic staff make referrals to mental health services. Again, due to the distances involved, generally people are chemically restrained and sent via plane. The closest community to Kalgoorlie on the Ngaanyatjarra lands is 750km km by road. The furthest, Tjukurla), is 1062.kms by road in comparison to 810km by road from Alice Springs. Perth is an additional 595km from Kalgoorlie. As Alice Springs is generally the regional centre used by Anangu, if someone is evacuated to Perth it quite common for this to be his or her first trip to that city.

(Anonymous, Northern Territory Submission #271)

Generally when people are assessed by the mental health team, they are transported back to their community with a referral and information passed on to the clinic nurse re: medication. It is important to note that this is the best possible discharge plan available when the system works effectively. There are many examples of even this level of support not being provided. For example: people being sent back to community without clinic staff being aware of the discharge plan or given any information.

(Anonymous, Northern Territory Submission #271)

There is then no follow up mechanism in place, except at the initiation of clinic staff. As there are no visiting mental health staff on the Ngaanyatjarra lands, for medication to be reviewed people have to travel to Kalgoorlie. Again it is clinic staff who are responsible for administering medications. It is important to place this in the context of an extremely busy workload, at times in a single nurse clinic. As primary health providers, Ngaanyatjarra Health is under resourced to provide basic primary health. There is extreme difficulty in recruiting and retaining experienced medical staff in remote areas.

(Anonymous, Northern Territory Submission #271)

Ngaanyatjarra Health receives a small amount of funding through the Bringing Them Home program. One worker is employed to provide services in the 159,948 km area. The focus of the funding is to provide grief and loss support in relation to issues of cultural dislocation and policies of forced removal.

(Anonymous, Northern Territory Submission #271)

Anangu living on Ngaanyatjarra Lands have no access to other types of mental health services except for the services described above. Even if the health system works at its' optimum level there are critical and serious service provision gaps.

(Anonymous, Northern Territory Submission #271)
6.5.11.4.11 Lack of appropriate treatment and support services for consumers in the criminal justice system

Although consumers who are subject to the criminal justice system are ensured access to a comprehensive range of treatment and support services (Standard 11.4.7) concerns were expressed regarding the availability and quality of such services. In particular, access to treatment for Borderline Personality Disorder was raised. Problems with forensic committees and the absence of a Chair of Forensic Medicine were also raised as problems impeding the planning and delivery of services to consumers in the criminal justice system:

My primary concerns in relation to mental health, are the extremely high rates of incarcerated women (and men) with both diagnosed and undiagnosed mental illness, and furthermore the treatment they receive from health services whilst in prison. There are also serious issues relating to treatment post release from community mental health services ...

(Service provider, Western Australia, Submission #14)

I know I do not have to outline the issues related to dual diagnosis, which this client group exemplify. Particular problems also arise for this client group when a Borderline Personality diagnosis is given, which is very often.

(Service provider, Western Australia, Submission #14)

I like others sit on various committees including forensic committees. These consumers are probably the most disenfranchised of the lot! There is no Chair of Forensic Medicine in WA ...

(Carer, Western Australia, West Perth Forum #43)

6.5.11.4.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.

I see a mistake that was made many years ago, and that was closing down the institutions without putting another better and cheaper way of allowing clients to live with some dignity.

(Consumer Advocate, Western Australia, Submission #35)

Under this Standard, submissions and presentations indicate concerns about:

  • difficulties accessing community based services;
  • lack of support for children of parents with mental illness;
  • need for living skills programs;
  • access to leisure and recreation programs is being reduced;
  • more support needed to strengthen valued relationships; and
  • lack of access to family centred approaches.
6.5.11.4.A.1 Difficulty accessing community based services

There need to be more community based treatments available for mental health consumers (especially job placements), voluntary work, educational achievements (at TAFEs) (anything to keep the self-esteem of a mental health consumer as this will develop positive outcomes).

(Anonymous, Western Australia, Submission #243)

The aim of deinstutionalisation was to provide treatment and support in the least restrictive setting, which for most people means living in the community. However, as discussed above, the necessary treatment, support services and systems have not been sufficiently developed. This is true for people with serious mental illness living in the community and for people who, as a consequence of failure to access treatment and support services at the onset of illness, develop significant disability and require additional community support services to live independently or with their family:

We provide a comprehensive service. It is difficult to link mental health clients to get community based services ...It seems to be a big problem with links to mental health clinicians linking in with the discharge planning. Mental health patients are not linked in to home help.

(Social worker at Regional Hospital, Western Australia, Geraldton Forum #84)

HACC [Home and Community Care] services, meals on wheels two years ago went under the hospital banner and we had numerous problems. At the moment the waiting list is long for these services ...Everywhere else in the state it is run by the community and Local Governments.

(Anonymous, Western Australia, Geraldton Forum #69)

St Bartholomew's House provided a description of their program to support consumers with severe mental illness to live independently in the community with dignity and respect:

St Bartholomew's House ...also has a very successful Independent Living Program, which provides benevolent landlord support for 60 people with severe and persistent mental illnesses to live in the community. The three crisis units receive clinical support from their respective local mental health service as does the Independent Living Program. In these programs, people who are living with mental illnesses can expect and receive the dignity and respect any person should be shown. In most cases the clinical support is appropriate and there have been good partnerships established to continue to ensure each individual receives quality care.

(St Bartholomew's House Inc, Western Australia, Submission #37)
6.5.11.4.A.2 Lack of support for children of parents with mental illness

The lack of programs and services to support children of parents with mental illness was 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 the case:

...to request funding for the growing number of children in the Program, which now totals 40. So much work has been completed through the COPMI Project in WA, yet the children remain unsupported. Unfortunately, the application was not successful and we have been referred to DCD and Lotterywest to pursue the Project, a Project I believe that Mental Health should be funding as part of an early intervention and prevention strategy. I do not think that the Office of Mental Health appreciate the lengths to which many NGO's go to try and come up with innovative ways to support this group of people and many of the workers in mental health in WA are extremely united and dedicated.

(NGO Service Provider, Western Australia, Submission #18)
6.5.11.4.A.3 Need for living skills programs

With the current crisis in lack of availability of supported accommodation, reports indicate that in many cases consumers either became homeless or return to live with their family. In many instances, this places intolerable strain on families as they wait for places to become available, as consumers lacked the skills to live independently and other support services are not available.

Treatment and support which maximises opportunities for consumers to live independently in their own accommodation (Standard 11.4.A.13), or provides sufficient scope and balance so that consumers develop or redevelop the necessary competence to meet their own everyday community living needs (Standard 11.4.A.2), is required. Such programs would enable consumers to live with dignity in society and are seen as critical. As with the decline in other services, living skills programs appear to have also been cut:

We need a service here in Bunbury that teaches living skills. It is my understanding that there was someone here doing that once but not anymore. It seems that living skills are the last thing on the agenda for mental health services.

(Support worker, Western Australia, Bunbury Forum #13)

We have 12 houses and a boarding house for single men so we can take in 18 men ...A lot of people with mental illness don't have independent living skills but people are regularly dumped on our doorstep - there's now at least one person a week "referred" by department officials to us. These "referrals" are occurring irrespective of the appropriateness of the referral. I have heard of stories where people end up in jail because there is nowhere else to take them.

(Community housing provider, Western Australia, Bunbury Forum #12)

...the need for Bunbury to have a Living Skills Centre for people to attend on a regular basis. Again I would like to point out this will have little or no real value to those living in isolated rural districts who have neither the means or the time frame to attend...has suggested the provision of a mobile unit which could services several communities. This of course would require ongoing funding, which in itself has always been a problem to the regions. The response to this suggestion from the Health Department has centred on the Department's policy of people with psychiatric illnesses partaking in existing community based activity rather than creating needs-specific services. The problem for many is two fold, being 1) there are no appropriate community based services in many of the rural areas. 2) Living in small community's people
are often reluctant to join any social or training activities or feel ill at ease for a myriad of reasons.

(NGO Service Provider, Western Australia, Submission #45)

Issues of Bunbury Mental Health Services:

•  The living skills program has not been functioning since December 2003, when after the resignation of a staff member the position has not been advertised or filled. This has had a huge impact on people living in the community in that there is no rehabilitation activities taking place. This is further exacerbated by very limited rehabilitation program therapy taking place at the in patient unit again this is associated with staff positions not being filled.

(Advocate, Western Australia , Submission #2)
6.5.11.4.A.4 Access to leisure and recreation programs is being reduced

Access to day programs to meet the needs for leisure and recreation (Standard 11.4.A.4) were also reported to be declining even though access to such programs is seen as critical for consumers to live in the community:

We were informed a couple of months ago that the facility which allowed [X] to attend the Creative Expression sessions which he has enjoyed up to now would shortly be denied to him. This was because the facility would in future cater only for patients who were either in Graylands Hospital or recently released from the hospital. The aim would be for patients to reach a 'goal' which would enable them to be trained sufficiently to be teachers or presumably fully fledged artists. This should occur over a 3 to 4 month period, and then they would be discharged from the facility and not allowed back. This appears to be a typical consultant "bean-counter's" solution to cut costs. Anyone who has had any experience in dealing with schizophrenia and many other mental illnesses will know that for patients to achieve goals in a certain time frame is nigh on impossible. Art and music therapy is well known to have a calming and therapeutic effect on the mentally ill, and will help to act as a preventative to further breakdown, which in turn would require further medication and possibly repeat hospitalisation. Thus it almost certainly helps in fact to reduce overall costs of treating the mentally ill, as the costs are minimal compared to the costs of hospitalisation, with its requirement of beds, accommodation, staffing etc.

(Carers, Parents, Western Australia, Submission #76)
6.5.11.4.A.5 More support needed to strengthen valued relationships

Many reports were received from carers, NGO and family workers describing the incredible strain that has been placed on families. In particular, the strain placed on family relationships due to an inability for consumers and carers to access services was noted. The importance however of such relationships and the need for mental health services to strengthen them through the provision of treatment and support is recognised by Standard 11.4.A.11 which states: 'The consumer has the opportunity to strengthen their valued relationships through the treatment and support effected by the MHS'.

Carers WA and the Mental Health Carers Issues Network recently conducted research into the needs and issues of carers of people with mental illness ...What is the best part of being a carer? For many carers the best part of being a carer related to personal growth and the opportunities provided to develop stronger family relationships. Providing care within the family was identified by 29% of carers who reported that caring for their family member with mental illness had enhanced the bonding within their family and maintained and strengthened family relationships ...Of significant note is that 19% of carers reported that there was nothing good about their role or experience as a carer. (author's emphasis) (McKeague B, 2003. Worried, Tired & Alone - A report of Mental Health Carers' Issues in WA. Briefing Paper)

(Carers WA, Western Australia, Submission #277)
6.5.11.4.A.6 Lack of access to family centred approaches

Carers expressed concern that their role in the treatment and support process was overlooked, resulting in their contribution not being acknowledged and their needs not being considered. In particular, the lack of access to family-centred approaches support groups was mentioned. 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'.

Carers also have their own needs which are completely overlooked as their role is not even acknowledged. Carers want mental health services to adopt a Family Inclusive Approach to mental health care which acknowledges and assesses both the needs of people with mental illness and their carers.

(Carers WA, Western Australia, Submission #277)

Carers WA and the Mental Health Carers Issues Network recently conducted research into the needs and issues of carers of people with mental illness ...What would make your role as a carer easier? Support from mental health service providers was identified by 25% of carers. This included an increase in the level of mental health services available; visits from nurses and other staff at home; better access to information; more support from carer support groups and organisations; and more support services and activities for their family members/friends with mental illness. (author's emphasis) (McKeague B, 2003. Worried, Tired & Alone - A report of Mental Health Carers' Issues in WA. Briefing Paper)

(Carers WA, Western Australia, Submission #277)

6.5.11.4.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.

Supported accommodation is in extremely short supply - at 80% below the national per capita average.

(SANE Australia, National, Submission #302)

Under this Standard, submissions and presentations indicate concerns about:

  • lack of funding for services and support;
  • lack of supported accommodation options for people in rural and regional areas;
  • a range of accommodation options is needed;
  • lack of supported accommodation for people with complex needs (mental illness, drug and alcohol, homeless, aged); and
  • lack of resources and support services for NGO supported accommodation providers.
6.5.11.4.B.1 Lack of funding for services and support

Lack of access to supported accommodation was noted as a critical problem by consumers, carers, clinicians and service providers. The result of there being no accommodation available meant that either consumers became homeless, accommodation services took on consumers that they could not adequately support (and therefore placed that consumer and other staff and residents at risk), or families were faced with a dilemma to take on the caring role and place substantial strain on the family unit. A critical lack of funding was noted in many submissions:

...is a non government organisation which provides housing and support to people with psychiatric disabilities in the Swan Region of Perth. We have been providing these services for 8 years now and have a waitlist for housing of between 40 and 50 people. It is almost an embarrassment to do an assessment for housing and then have to inform applicants that the waitlist is 3 to 4 years long ... We are also now in the position where we are housing people when properties become available, without the capacity to support them in their housing.

(NGO Service Provider, Western Australia, Submission #18)

In 2002, NGO's were invited by the Office of Mental Health to tender for disability support services. Many I know worked extremely hard to put in their submissions, only to be advised in writing the following year, that no funding would be forthcoming. Last year, as you may already know, all NGO's in WA were under scrutiny and fortunately, the sector united and lobbied and the cuts were halted. It reminded me of a statement I read in 'Out of Hospital, Out of Mind' that said something like 'If you are up to your arse fighting the crocodiles, then you forget that your real job was to go in there and drain the swamp'. That is certainly the case for NGO's in WA in 2002 ... NGO's should not be expected to house people with mental illness and not have the capacity to support them towards recovery and community living.

(NGO Service Provider, Western Australia, Submission #18)

It is obvious that the basic needs of mental health clients are not being met and that without additional resources SAAP services cannot accommodate people with complex needs.

(St Bartholomew's House Inc, Western Australia, Submission #37)

Hostels like St. Bartholomew's House can no longer afford the risk of injury to staff and/or other residents from people who are not having adequate treatment and support from mental health services.

(St Bartholomew's House Inc, Western Australia, Submission #37)
6.5.11.4.B.2 Lack of supported accommodation options for people in rural and regional areas

The problem of the lack of supported accommodation options was most keenly felt in rural and regional areas:

...However, there needs to be noted the greater lack of suitable accommodation for those living in rural areas ...at the moment most local consumer have to remain living at home in what for some is less than favourable circumstances, the alternative is for them to move to Bunbury or at least Busselton which means leaving support networks of family and / or friends.

(NGO Service Provider, Western Australia, Submission #45)
6.5.11.4.B.3 Range of accommodation options needed

Most notably, many submissions argued that a range of accommodation options were needed and that these needed to be flexible:

Carers report that the current funding and provision of mental health care in WA is clearly inadequate to meet the level of need. This is demonstrated by: The lack of independent accommodation options for people with mental illness. There should be a range of options available and flexible to the individual needs of people with mental illness.

(Carers WA, Western Australia, Submission #277)

A huge area lacking in the mental health system overall is the lack of some form of interim accommodation like houses or hostels for patients who have recovered to the extent that they no longer require hospitalisation, but still require some overall supervision in a secure environment to give them their medication regularly and help to prepare them for release into the community. We have come across patients in Graylands hospital who have been there for many months, and have really nowhere to go where they can still be supervised and helped to rehabilitate.

(Carers, Parents, Western Australia, Submission #76)

Apparently all of the psychiatric hostels are privately run and they can then pick & choose who they will allow to reside at the hostels. This means that for difficult or disruptive patients, there is nowhere for them to go.

(Anonymous, Western Australia, Submission #145).

It is our contention that hostel type units should be built or allocated for the use of high care clients, funded to include a high care worker, a type of half-way house. This would also act as a Transitional House where young people (20-40 yrs) can learn life skills, work skills, to enhance life long Self Care.

(Consumer Advocate, Western Australia, Submission #35)

We have trying for many years to get some recognition that there is a real need. The answer that is always the same that it is considered to be more affective for all clients to live in an open environment. I know that is true in most cases but there are many who do not fit that category. Some may grow into a different lifestyle, others never will ...Last week a long term client had an altercation with a man living in the same street this is an example of what often happens in this situation.

(Consumer Advocate, Western Australia, Submission #35)

This young man now has two fines which he will not pay. He needs a 'sheltered living hostel', a mentor, some work under supervision, like the Work for the Dole project. It is my contention that a program such as this is not more expensive than the present cost to the community and it may be good for him. He is a walking advertisement for the failure of Mental Health Services to support vulnerable people like him.

(Consumer Advocate, Western Australia, Submission #35)

The need for respite services was also noted for the consumer. The need for such services is also seen as essential for the carer and the family when consumers are living with family members:

...I do think some intensive respite care can go long way to saving lives of the mentally ill when they are in crisis.

(Carer, Sister, Western Australia, Submission #101)

Respite for carers, time away from the caring role, is essential to maintaining the care relationship and improving the quality of life of carers and their family members / friends with mental illness. Without it there is the danger of relationship stress and breakdown and social isolation. Carers continually report their need for respite and their difficulty in accessing it. A specific respite program for carers of people with mental illness is required in WA as they aren't a recognised target group for other Commonwealth and State funded programs.

(Carers WA, Western Australia, Submission #277)

There is no available respite for families / carers of those people with mental health issues. However, for a carer of someone with an intellectual disability resources are available for respite. This raises another concern which is for that of the mental and physical health of the carer. (I have seen the health of carers and their families - including young children - deteriorate as they struggle to cope with their loved one).

(Anonymous, Western Australia, Submission #145)
6.5.11.4.B.4 Lack of supported accommodation for people with complex needs (mental illness, drug and alcohol, homeless, aged)

Of the small number of accommodation services operating, most dealt with one particular 'group' (e.g. mental illness, homelessness, elderly, youth, drug and alcohol etc.). These accommodation services were generally overstretched, operating at capacity with waiting lists and under-resourced. Most are not capable of dealing with clients with complex needs. Some services have attempted to take on people with complex needs even though they did not have the capacity to do so. Sometimes this decision results in serious risks for the consumers, staff and other residents. From the nature of the submissions received, it appears that there is a growing number of people with complex needs with nowhere to go:

St Bartholomew's House has been providing accommodation and support for people experiencing homelessness for 40 years. Over that time the profile of the people accessing the service has changed. Previously, men were older and most had an alcohol issue. Today the average age for admission in the supported accommodation area is 28 years and men are presenting with complex needs. Many have alcohol and drug issues and/or mental illnesses.

(St Bartholomew's House, Western Australia, Submission #37)

St Bartholomew's had found in 2001 a situation where over 60% of its clients were potentially involved with mental health issues. It was utilised as a quasi-psychiatric service without any resources with respect to this aspect of care. Mental Health Services all over the area were discharging clients directly to St Bartholomew's ... (excerpt from Coroners Report, 2004)

(St Bartholomew's House Inc, Western Australia, Submission #37)

...A large number of people with mental health issues fluctuate in the severity of their symptoms and those which are chronic as opposed to acute are frequently discharged from appropriate facilities with no where to go. (excerpt from Coroners Report, 2004)

(St Bartholomew's House Inc, Western Australia, Submission #37)

My son is 19 and he has chronic schizophrenia and a drug abuse problem - he's been in the locked ward at Graylands for quite a while and I'm glad he's been locked up for that long because he can't cope outside the hospital. He lives with me and I worry about what will happen to him if he is released - he can't be accommodated anywhere and this is a human rights issue - there's unreasonable pressure on the family to provide care for really sick people like my son. But one of the big problems is how much people are charged to be in supported accommodation - 80% of a person's income for supported accommodation is too much because it just leaves enough for cigarettes. My son can't even get supported accommodation. He was assessed and because he said he wouldn't give up his cannabis - (he can't lie) they won't accept him. So it's really hard, because my son doesn't have the cognitive skills to give them the answers they want he gets punished. I wish I could teach him how to lie. These kids with co morbid problems like my son are becoming the new generation of homeless people. I have been contacted by a lady who has a daughter on benzo's and if she didn't provide care and accommodation for her daughter she'd be under the bridge.

(Carer, Mother, Western Australia, West Perth Forum #31)

Due to a lack of appropriate facilities for persons with mental health issues and substance abuse issues, many emergency accommodation hostels find themselves in the position of having to accommodate people with disabilities they are not resourced to care for appropriately. A large percentage of homeless persons have nowhere to go if not accommodated by hostels such as St. Bartholomew's. (excerpt from CORONERS REPORT, 2004)

(St Bartholomew's House Inc, Western Australia, Submission #37)
6.5.11.4.B.5 Lack of resources and support services for NGO supported accommodation providers

The combination of a lack of community services, overstretched community services, lack of funding for supported accommodation and the growing number of people with complex needs has resulted in consumers being placed at risk:

The Community Mental Health Team from the Perth Hospital provides support to the Hostel with clinical services but each nurse's workload is considerable and if a person is unwell they are often not able to get them an inpatient bed. Nurses refill dossett boxes and mange medications but are reluctant to write in residents files when they visit or medicate residents. This puts residents at risk because St Bartholomew's House staff do not know what is going on if a resident has an adverse reaction to a treatment or whether he has had his regularly injection. All care plans are kept in the hospital.

(St Bartholomew's House Inc, Western Australia, Submission #37)

In November 2002 a resident died from an overdose of Quetapine. The gentlemen had been a resident at St Bartholomew's House for 6 months. He had a long psychiatric history. The Coroner was supportive of St Bartholomew's House and the care provided, but was very concerned about the number of people with mental illnesses whose cases come before the Coroner's court (see attached Coroner's Finding).

(St Bartholomew's House Inc, Western Australia, Submission #37)

6.5.11.4.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, submissions and presentations indicate concerns about:

  • the over reliance on medication; and
  • increasing use of Electro Convulsive Therapy (ECT).
6.5.11.4.C.1 Over reliance on medication

Reports were received indicating that, in hospital settings, there was an over reliance on medication and very little emphasis or choice from a range of accepted therapies.

The other patients left back in the hospital would like me to tell you that the Bunbury Hospital is a place where you get medicated first and counselling second. It's a place where you can get away from the world but there's not much else.

(Consumer, Western Australia, Bunbury Forum #17)

Medication as the only treatment modality. Consumers of public mental health services, as in patients or in the community, rarely have an opportunity to 'talk through' the contents of their thoughts, their ideas about the causation of their illness, or the progressive processing or understanding they are developing about their condition. The structure of mental health services means that frequent turnover of staff leads to discontinuous relationships between consumers and doctors. Medication has become the primary treatment modality. Most consultations centre around negotiations on dose, medication type, combinations, side-effects, and consumer concerns about being on chemical treatments ...

(Health Consumers' Council WA, Western Australia, Submission #29)

The failure to engage with these consumers through any other form of treatment, including talking therapy, leaves no options but to continue on medication. When consumers succeed in having their dosage significantly reduced, any behaviour that results from the freedom from sedative effects and disabling side effects are readily considered to be manifestations of illness. Family and others who have felt comforted by mental health services' reliance on medication are easily threatened by medication reductions and are not inhibited about reporting changes in behaviour to mental health services. The tendency to rely upon third party information can lead to pressure from clinicians to increase medication levels ...

(Health Consumers' Council WA, Western Australia, Submission #29)
6.5.11.4.C.2 Increasing use of Electro Convulsive Therapy (ECT)

Concern was also raised about the increasing use of Electro Convulsive Therapy in Western Australia:

ECT [Electro-Convulsive Therapy] use is increasing in WA, in both public and private hospitals. There was a marked 25% increase in ECT hospitalisations in the financial year 2000/01 (618), compared with the previous year 1999/00 (495). 63% of these hospitalisations were in private hospitals. Why is this the case? ...The majority of hospitalisations for ECT treatment in 2001were female (70%) ...There is no standard protocol for the administering of ECT over all hospitals. Individual hospitals have their own clinical protocols, including voltage, area of administration and number of treatments. While a standard protocol for public hospitals is being addressed, the private hospitals adhere to their own individual policies. Elderly patients (24% of ECT patients were over 65 years) are being given "maintenance ECT" with no other treatment, and no treatment plan. Patients are not fully informed of the multitude of side effects associated with ECT. There has been a move away from unilateral ECT (which was thought to minimise side effects) to bilateral ECT. A review of the literature indicates there is little agreement amongst ECT "Experts" about ECT procedures. Issues such as current, electrode placement, and number of treatments remain controversial. I do not believe the public are aware of the extent of ECT use. In my opinion, ECT is an unacceptable treatment. If it is used at all, ECT should be given as an absolute last resort, under the most stringent guidelines. Currently ECT is being given in an ad hoc manner.

(Giz Watson MLC, Western Australia, Submission #171)

6.5.11.4.D Therapies

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

Under this Standard, submissions and presentations indicate concerns about:

  • the lack of access to a range of therapies - emphasis on medication.
6.5.11.4.D.1 Lack of access to a range of therapies - emphasis on medication

Following on from the emphasis on medication noted above, was another report that the main emphasis of mental health treatment was on medication with little or no access to a range of safe and effective therapies and rehabilitation approaches:

Mum overdosed on the anti-depressants she had been prescribed, taking 96 of them in one sitting. She had so many anti-depressant pills to take that she had a plastic box labelled with the day, each one containing 4 or 5 tablets. As I recollect, over the twenty year period, she was not offered counselling outside of her GP and all treatment seemed to be purely pharmaceutical.

(Son, Western Australia, Submission #87)

I feel the inpatient unit in Bunbury provides a second-rate service to the mentally ill in the region as it does not provide a multi-disciplinary team. The Therapy Department went from 4 Full Time Employees, providing a day-service to clients for six-weeks intensive therapy to prevent hospital admissions, to now only 1.5 FTE, providing only an abbreviated day program to the current inpatients. The therapy department is now housed in the nursing station of the High Dependency Unit, due to the Community Staff moving into their space when they lost their premises. The patients have lost their group room, which now houses community staff, desks and computers. The whole APU [Acute Psychiatric Unit] is an overcrowded situation with the community staff moving into the small premises.

(Nurse, Western Australia, Submission #55)

Only recently in July, Carers at a Carer Advocacy & Issues Forum in Bunbury met and expressed their frustration regarding the sudden closure of mental health services in their community. Specific concerns regarding the closure of services include: The community service has been relocated to the already limited space at the inpatient facility. This has resulted in further restrictions to the declining availability of therapy for inpatients; The lack of living skills, acute therapy and rehabilitation services ...

(Carers WA, Western Australia, Submission #277)

Reluctance to recognise consumer experience of past trauma that contributes to mental illness and distress. This deafness to the consumer narrative reflects a wholesale abandonment of talking and listening therapy in state mental health services ...

(Health Consumers' Council WA, Western Australia, Submission #29)

6.5.11.4.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:

  • care not being provided in the least restrictive environment;
  • deaths while an inpatient;
  • lack of beds;
  • lack of access to clinical MH staff;
  • impact of admission on consumers family not minimised;
  • voluntary admission not supported;
  • transport not most respectful;
  • problems with increasing use of security guards in hospital settings due to a shortage of secure beds; and
  • lack of supervision and adherence to protocols.
6.5.11.4.E.1 Care not being provided in the least restrictive environment

Serious concerns were expressed through submissions and personal accounts told at the forums that care was generally not provided in the least restrictive environment. The following comments are a sample of this evidence:

It is hospital policy to sedate them and shackle them.

(GP, Western Australia, Geraldton Forum #54)

...higher levels of 'anger and aggression' and 'control' and lower levels of 'autonomy'. While ideally it would be useful to compare Grayland's wards with similar clinical areas within Australia these findings of negative characteristics are a cause for concern though not surprising given the custodial culture that prevails in the hospital.

(Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

I'm a patient in the hospital at the moment under an involuntary order and it was very difficult for me to get here to this forum today. The other patients left back in the hospital would like me to tell you that the Bunbury Hospital is a place where you get medicated first and counselling second. It's a place where you can get away from the world but there's not much else. The situation is terrible and I can't even have a shower in private. I'm scared and I have no privacy.

(Consumer, Western Australia, Bunbury Forum #17)

...Culture of custody and control which is prevalent in WA. What we have at the moment is a mental health system that's taking money away from non-secure beds to secure beds. Part of the culture of control is the resistance to addressing a person - civil liberties.

(Consumer Advocate, Western Australia, West Perth Forum #36B)
6.5.11.4.E.2 Deaths while an inpatient

Of most serious concern were reports of deaths of consumers while an inpatient and that hospitals did not provide safe settings:

...Graylands Hospital ...The place is a nightmare of mammoth proportions and at the moment I am writing a book showing such facts along with the death of my daughter there, along with other young adults. It is usual to go to a hospital to improve one's health...these young people are dying through neglect by hospital staff and not being listened to. Certainly no fault of their own. I have searched long and hard and if I honestly believed that my daughter and the others I know of had died through their own doing and with compassion behind them I would leave well alone. They didn't - they died in strange circumstances.

(Carer, Mother, Western Australia, Submission #103)

Attempts were made to locate a facility to meet the needs of my sister. It is my understanding that of all the hospitals with closed wards, there were no beds available that evening. Eventually after a long delay, she was transferred to the psychiatric unit at Royal Perth Hospital in the Perth CBD. She stayed there the night but was not in a locked ward. In the morning she walked out of the hospital. She walked less than 500m to a multilevel carpark on the corner of Wellington and Pier Streets. She went to the top floor and jumped to her death...It was unnecessary tragedy that could and should have been averted. There are many questions unanswered for my family: How can this happen? Who is accountable? Why are there insufficient resources when the problem is so evident?...the system failed my sister and her family. It is unacceptable and these issues need to be voiced and addressed...I was unable to return to this job after my loss.

(Brother, Western Australia, Submission #89)

Concern around the circumstances of an alleged suicide while an inpatient.

(Carer, Western Australia, Submission #196)
6.5.11.4.E.3 Lack of beds

The lack of beds was a vexed issue for many people. Some considered the Government's focus on increasing bed numbers as problematic because it failed to take into account the need to invest in effective systems of community-based care that would ultimately reduce reliance on hospital beds. For others, the lack of available beds for people with acute mental illness presented significant distress and a failure of Government to respond to the acute needs of people with a mental illness:

Another big problem is around the number of involuntary beds we have in Bunbury Hospital. Once before we had these beds, then they were "taken away", now we have them again but the number is completely inadequate to our needs in this community.

(GP, Western Australia, Bunbury Forum #19)

As the APU [Acute Psychiatric Unit] is not a secure unit and cannot manage high risk patients, there often becomes a need to transfer patients to the more acute units in Perth. The process of transferring a patient to Perth is a lengthy process due to shortages of beds. The result of this is that patients are kept in the APU, the Medical Ward, the Intensive Care Unit and the Emergency Department of the hospital under 'guard', with IV sedation for an extraordinary number of hours or even days. The over-use of the seclusion room in APU on a couple of occasions to detain patients also comes to mind. There was in an occasion where a patient was detained in the medical ward with a guard for five days before a bed became available.

(Nurse, Western Australia, Submission #55)

There are not enough beds for mental health patients which means that the few beds available go to the "deserving few" - whatever that means, presumably it means those people who do not have a drug/alcohol problem.

(Anonymous, Western Australia, Submission #145)

...it is also worth noting that the Consultant Psychiatrist who admitted her had to almost beg for the last bed on the ward, otherwise the client, who was suicidal, would have been sent home with no support. The doctor informed me that on the previous day, he had wasted 3 hours of his clinic time chasing a bed for an extremely unwell patient. His other patients could not be seen due to this.

(Social Worker, Western Australia, Submission #15)

(iii) patients placed "on leave" to make way for new admissions. If a patient is ready to leave hospital the team would have discharged them, obviously these patients are not ready! The strain is then transferred to the family/carers/community teams. The risks of this practice are patently obvious; once again I was forced to agree to this occurring in North metro over the weekend, the only other option would be to refuse admission.

(Consumer Advocate, Western Australia, Submission #338)

(iv) "civil" patients being admitted to the Frankland Center [sic]. This is a forensic mental health facility, the practice exposes the acutely unwell patients to an highly traumatic experience ...

(Consumer Advocate, Western Australia, Submission #338)

...ongoing problems that I personally know exist at one hospital emergency department ... Frequently there are no beds of either sort available. In the case of involuntary patients they have to be held on forms in cubicles or other appropriate places until a bed can be found which can take a considerable amount of time. This type of situation places not only the patient but also their family / carer under additional distress and is a denial of the human right to the best available health care ...

(Carer Advocate, Western Australia, Submission #339)
6.5.11.4.E.4 Lack of access to clinincal MH staff

In addition to lack of access to hospital beds, the lack of access to suitably qualified staff was also raised as a problem:

My friend wasn't under a section but she was in hospital and didn't see a psychiatrist for three days.

(Consumer, Western Australia, Bunbury Forum #3)
6.5.11.4.E.5 Impact of admission on consumers family not minimised

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 'care of dependant children'. According to one presentation at the forum held in Bunbury, no arrangements were made for the care of dependant children when their mother was admitted to hospital.

The police were fantastic with that woman but there was nothing done for her children when she was taken away.

(Friend, Western Australia, Bunbury Forum #3)
6.5.11.4.E.6 Voluntary admission not supported

One carer reported the excessive use of chemical restraint for a consumer who was seeking voluntary admission. According to Standard 11.4.E.2: 'Where admission to an inpatient psychiatric facility is required, the MHS makes every attempt to promote voluntary admission for the consumer'.

[X] was kept heavily sedated: [X] was in and out of drug induced sleep for approximately 18 hours until admission at Graylands Hospital. Surely this is way too long and unnecessary considering the fact that [X] was voluntarily seeking treatment! During the assessment stage at the Emergency Department of Bunbury Regional Hospital, [X] had been calm and fully compliant. No grounds were shown for involuntary admission witnessed by parents, security and nursing staff.

(Carers, Western Australia, Submission #177)

Coercive use of involuntary status to secure compliance with treatment - you're only voluntary if you do what we say, including taking the treatment we propose and staying within the walls of the inpatient unit

(Health Consumers' Council WA, Western Australia, Submission #29)
6.5.11.4.E.7 Transport not most respectful

Standard 11.4.3.E states: 'The MHS ensures that a consumer who requires involuntary admission is conveyed to hospital in the safest and most respectful manner possible'. The following account raises serious concerns on a number of levels, not the least of which is the mode of transportation not being the most respectful (sedation with police escort) when the consumer's father was prepared to drive the consumer as the consumer was not in an agitated state. The reason for escort (the consumer had been made an involuntary patient) had not been discussed with either the consumer of his carers.

Parents transported [X] to the Bunbury Regional Hospital (Emergency Department), at his request. [X] requested ED staff to have him admitted on to a psychiatric unit. [X] was willing and cooperative ...Dr [Y] entered the interview room and advised that [X] was going to Graylands Hospital. Dr [Y] quickly left the room. Shortly thereafter, a security guard entered the room and explained to the patient that he would be sedated and transported at 0800 the next morning. At this point [X]'s parents spoke to Dr [Y] and asked why [X] required to be sedated? Dr [Y] responded with "we do it this way". [X]'s Father once again stated that he was willing to transport the patient to Graylands and that "if it was a matter of legalities, he was willing to take full responsibility and sign any documents whatsoever for this to happen" ...Father spoke with nursing staff at the Emergency Department to determine why transportation had not taken place as scheduled at 0800 hours...Ambulance staff had refused to take charge of the patient because he was sedated. A Form 3 had to be raised and police escort arranged ...At no stage whatsoever, up until [X] had been placed into an induced sleep, had medical staff at the Bunbury Regional Hospital, notified [X] or us, that he would be made an 'Involuntary Patient'.

(Carers, Western Australia, Submission #177)

One thing that concerns me personally is the transport of people with a mental illness. We are often required to transport these people but they are not criminals, they are ill.

(Police officer, Western Australia, Bunbury Forum #9)

Consumers are driven in the back of paddy wagons - three day trips - from Kununurra to Perth.

(Carers, Western Australia, West Perth Forum #43)

There are conflicting reports that the Royal Flying Doctor Service may not want to take the clients. Sometimes consumers have to wait another day to be sedated and possibly have a police escort to take them to Graylands. Sometimes they need armed escort.

(GP, Western Australia, Geraldton Forum #52)
6.5.11.4.E.8 Problems with increasing use of security guards in hospital settings due to a shortage of secure beds

As stated previously (Standard 2 - Safety), the shortage of secure beds has resulted in the increased use of security guards to monitor patients in hospital settings. This has had the result of not only focussing the issue on containment rather than care, but also compromising the safety of both the consumer and security guards who are not trained for such situations as demonstrated by the following reports:

One of the most disturbing practices for me is the use of security guards from a private security firm to facilitate the care of inpatients, due to lack of proper facilities and staffing levels in Bunbury. The hospital regularly employs guards to "special" patients who are considered at risk of either self-harm or absconding. They often use the guards to boost the staffing levels in the unit to try and make the environment safe. This can often mean an untrained person, usually male, following around a very ill or deeply disturbed person in the medical ward of the hospital as well as the psychiatric unit, or is sitting around in full uniform in the psychiatric unit. This has a couple of very major concerns. Firstly, the patient often self discloses to the security guard their personal history, which may often include a history of sexual abuse. Secondly, it also gives the patient, visitors and other patients, the impression that the person with the guard is "trouble", i.e. violent, bad, etc.

(Nurse, Western Australia Submission #55)

I have witnessed young male security guards following around young female patients, watching them in their bedrooms. I have seen the situation escalate whereby a young male security guard, who had a history of depression, suicidal ideation in the past, have to try and restrain a female who was absconding from the Unit (as it is open and not a secure environment). He failed to restrain her, she absconded and placed herself on a tower in Bunbury threatening to jump off. The security guard was so distraught from the incident, feeling that he was responsible for anything that happened to her, that he began crying and had to be consoled by staff.

(Nurse, Western Australia Submission #55)
6.5.11.4.E.9 Lack of supervision and adherence to protocols

Concern was expressed that policies and procedures are not in place to ensure that practices agreed to by clinical staff are being adhered to. Standard 11.4.E.15 states: 'Documented policies and procedures exist and are used to achieve the above criteria' and Standard 11.4.E.6 states 'The MHS monitors its performance in regard to the above criteria and utilises data collected to improve performance as part of a quality improvement process'. The following account also suggests problems with management and accountability to ensure the implementation of decisions made:

Lapses in practice unchecked by senior clinical nurses and nurse managers - Despite the involvement of all nursing staff in the decision making on changes made in the NPDU [Nursing Practice Development Unit], lapses by individual nurses were allowed to occur unchecked by senior clinical nurses and nurse managers.

(Excerpt from: Shanley (2001), Management of change in a psychiatric hospital using a 'bottom up' approach)
(Eamon Shanley, Professor of Mental Health Nursing, Australia, Submission #33)

6.5.11.5 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:

  • discharge without proper assessment;
  • inadequate discharge plans;
  • difficulty in coordinating community based services when exiting MHS; and
  • other service providers nominated on exit plan not informed prior to exit.
6.5.11.5.1 Discharge without proper assessment

Concerns were expressed that discharge was not based on an agreed exit plan or health status of the consumer and without a proper assessment. Such exits could jeopardise the safety of the consumer, especially as entry is almost always on the basis of risk or actual self-harm, or harm to others. According to Standard 11.5.2: 'The exit plan is reviewed in collaboration with the consumer, and with the consumer's informed consent, their carer's at each contact and as part of each review of the individual care plan'. Also, according to Standard 11.3.18, a review should be conducted when the consumer is going to exit the MHS, presumably to ensure that exit is occurring at an appropriate stage of the recovery process. The following account raises serious concerns regarding the review process and level of planning prior to discharge:

Discharged from Graylands Hospital ...after only some 15 ½ hours after admission into a locked facility. Considering that for the majority of this time, [X] was either heavily sedated or asleep during the night, surely this was insufficient time for a full assessment to be given and for the decision to be made that he was well enough to return to Bunbury.

(Carers, Western Australia, Submission #177)
6.5.11.5.2 Inadequate discharge plans

Concerns were expressed that discharge was occurring without appropriate planning and notification to either the consumer or carer. 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 cares 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'. This would also suggest that discharge plans had not been developed in collaboration with the consumer and, with their consent, their carer (Standard 11.5.2), that understandable information about the range of relevant services and supports had not been provided (Standard 11.5.4), and that consumers have not established contact with the service providers prior to exit (Standard 11.5.6). These plans are vital in order to ensure ongoing recovery, prevent relapse and ensure reintegration into society as fully as possible:

But then they sedated him even though I told them I would transport him to Graylands. 20 hours later after being in a drug induced state in Graylands he was discharged (the next morning) without any explanation to him or to us.

(Carer, Mother, Western Australia, Bunbury Forum #22)
6.5.11.5.3 Difficulty in coordinating community based services when exiting MHS

A presentation was also made at the Geraldton Forum suggesting that it is difficult to get clinicians involved with planning prior to discharge and that it was difficult to organise community-based services for consumers once they arrived home. This further supports the evidence presented regarding the lack of planning occurring prior to discharge and the lack of support services in the community which therefore necessitates engagement with carers in order to ensure support:

We provide a comprehensive service. It is difficult to link mental health clients to get community based services. There is difficulty getting mental health staff to work in with discharge of patients. It seems to be a big problem with mental health clinicians linking in with the discharge planning. Mental health patients are not linked in to home help.

(Social worker at Regional Hospital, Western Australia, Geraldton Forum #84)
6.5.11.5.4 Other service providers nominated on exit plan not informed prior to exit

Standard 11.5.6 states: 'The MHS ensures that consumers referred to other service providers have established contact and that the arrangements made for ongoing follow-up are satisfactory to the consumer, their carers and other service provider prior to exiting the MHS'. According to one carer, while staff had assured her that procedures had been followed and notifications made, the service provider was unaware of any plans prior to their arrival:

Mother was contacted by [X] advising that he was to be discharged and could she come and collect him from Fremantle. Before proceeding to Fremantle, mother contacted the Alma Street Centre staff to ensure allocation of case manager and accommodation were organised. Mother advised that these needs had been met. She also questioned staff as to whether the doctor believed he was well enough to leave as she did not believe this to be the case... The South West Community Mental Health team only became aware of [X]'s discharge when he arrived on their doorstep.

(Carers, Western Australia, Submission #177)

6.5.11.6 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:

  • discharge without involvement of carers prior to exit;
  • lack of follow-up;
  • individual care plans not being reviewed properly prior to exit; and
  • discharge while unwell due to lack of resources.
6.5.11.6.1 Discharge without involvement of carers prior to exit

Carers expressed frustration that they were not notified of the consumer's discharge from the MHS, especially as they were expected to assume responsibility of care upon exit from the MHS. This left carers with feelings of extreme stress and fear for the safety of their family member with mental illness. A clinician also expressed concern about the practice of excluding carers in the treatment and discharge process. The clinician acknowledged that as treatment and support services are not available to provide integrated and coordinated care after discharge then, in their absence, carers must be equipped to assume this role in order to ensure the best possible outcomes for the consumer:

My other concern is for the carers. They are told not to get involved but there's no one else to get involved. If the service doesn't want to involve carers then who do they think will provide the care once someone is discharged from a hospital? Who else is there?

(GP, Western Australia, Bunbury Forum #19)

My son was discharged from hospital and we didn't even know he had been discharged until he turned up on our doorstep. No one tried to inform us even though they knew he would come back to us because we are his carers.

(Carer, Mother, Western Australia, Bunbury Forum #22)
6.5.11.6.2 Lack of follow-up

One carer commented that although an arrangement had been made for the dispensing of medication, there was no other contact from the mental health service after discharge from an acute admission to ensure the health and safety of the consumer:

After his discharge from hospital [X] had a couple of appointments with the psychiatrist at Swan Valley Centre, then was discharged from there and told to go his GP for his medication. So far [X] has gone twice to be issued with 6 month repeat prescriptions. There has been no other contact - not even a phone call to ask how he is doing.

(Carer, Mother, Western Australia Submission #99)
6.5.11.6.3 Individual care plans not being reviewed properly prior to exit

Standard 11.6.1 states: 'Staff review the outcomes of treatment and support as well as on-going follow up arrangements for each consumer prior to their exit from the MHS'. Included in the notes to this Standard are 'perception of quality of life' and 'review of goals individual care plan'. One carer expressed concern that insufficient attention was paid to planning rehabilitation and follow-up prior to her son's discharge:

I feel my main concerns are that there is: NO FOLLOW UP ON DISCHARGE, NO REHABILITATION ON DISCHARGE. [X] said to me when he came out of hospital 'Mum what am I going to do with my life? I didn't know what to say. (author's emphasis)

(Carer, Mother, Western Australia Submission #99)
6.5.11.6.4 Discharged suddenly while still unwell due to lack of resources

Concern was expressed in one submission that a decision to discharge a patient was allegedly made on the basis of insufficient staff resources to enable a staff member to accompany a patient to attend court. As no-one was available and the patient needed to attend court, it is alleged that a decision was made to discharge the patient so they could attend, not on the basis that the patient had been assessed to be well enough to be discharged:

One particular patient was discharged from hospital in order to attend court and although the hospital wanted someone to accompany him and escort him to Court, there were no available resources to do this. The patient was discharged and never made it to court at all. The question stands: if he was well enough to be discharged, why was an escort sought?

(Anonymous, Western Australia, Submission #145)

6.5.12 STORIES OF HOMICIDE AND SUICIDE IN WESTERN AUSTRALIA

[X] was a devoted wife and mother of two. She was caring, giving, creative and ill. She was diagnosed with Bi-Polar Affective Disorder in her early 20's. She had a degree in Education, did not take drugs and would always cry out for help when it was often needed. She was not well, this is no secret. Her illness had led her to attempt to take her own life on several occasions. She however conformed to taking her medication and was, what I would consider to be, a person who wanted to live and was willing to do what ever it took for this to happen. On the night of the 29th July 2003 she admitted herself to Sir Charles Gardener Hospital in WA with the support of her husband. She recognised that she was having delusions and was contemplating suicide. This was made clear to the hospital in the admission. I would like to think that her previous history of illness and attempted suicides would have been familiar to the hospital given that she had been a patient in the closed ward of that hospital on a number of occasion - the last being within a few months of her most recent admission. Attempts were made to locate a facility to meet the needs of my sister. It is my understanding that of all the hospitals with closed wards, there were no beds available that evening. Eventually after a long delay, she was transferred to the psychiatric unit at Royal Perth Hospital in the Perth CBD. She stayed there the night but was not in a locked ward. In the morning she walked out of the hospital. She walked less than 500m to a multilevel carpark on the corner of Wellington and Pier Streets. She went to the top floor and jumped to her death.

(Brother, Western Australia , Submission #89)

I am an NGO provider - our surplus of funding from last year was taken from us by the Government without notice. The Government just doesn't think about the implications of taking away funding from NGOs. We already have long waiting lists and taking away funding makes them even longer. One of the young consumers who was on one of our waiting lists for 4 months was also caring for her Mum - she killed herself because she felt she couldn't cope looking after her mum anymore without some support. Waiting lists for support from us have gone up from 3 weeks to 4 months.

(NGO Provider, Western Australia , West Perth Forum #29)

My eldest child gassed himself in his car - after that when we really needed support there was hardly anything for us. It was the lack of support that led to my husband walking out - our family broke up because we had nowhere to turn for help. Then my 12 year old son tried to hang himself on the washing line - I got him down and we got treatment from a private psychologist but he later hung himself in his flat. I have lobbied through lifeline and parliament and I have got nowhere - I am not a judgmental person but I find Jim McGinty is aloof and doesn't care. We need to educate our young people about mental illness and about how to ask for help. Where's the money to educate our young people to ask for help?

(Carer, Mother, Western Australia , West Perth Forum #35)

My son has been diagnosed as paranoid schizophrenic since 1996. My wife and I looked after him for two years. He was charged with wilful murder in November 2000. He is now in prison facing a 20 year prison sentence. In 1999 he received threatening letters from his landlord. He rang me from Maylands. I was unable to leave my wife I was on call 24 hrs a day because she was ill and my son was in Perth . He was delusional and needed help. I spent 4 days I rang the crisis centre in Maylands Mental Health (PET) regularly and each time had to tell the full story - they wouldn't listen to me and wouldn't do anything. I rang the police nothing was done. They wouldn't do anything. After 3 ½ yrs in Graylands he is now better than he has ever been. He is now in Hakea prison. The help I got was none. For a dangerous situation there was no help available for me or my son.

(Carer, Father, Western Australia , Geraldton Forum #49)

My daughter's hanging was needless as were the high doses of medication and at her coronial enquiry many flaws were unearthed. An uncaring hospital who said they didn't believe she was suicidal even though she had driven herself there and one staff member said 'we didn't believe her as she was well mannered, articulate and attractive!' Her post mortem showed her to be a male of 44 when, obviously, she was female and 24.

(Carer, Mother, Western Australia , Submission #103)

My husband was suffering from Post Traumatic Stress Syndrome (undiagnosed) and spent all his waking hours thinking and talking about suicide. I had no idea where to get help and I think a local GP got me in touch with (probably) South West Mental Health. A male nurse came and visited us at home and we each in turn and in private talked to him. I explained that I felt sure that [X] would try to convince the nurse he was fine and it was in my imagination, which he successfully did. I explained to the nurse how desperate the situation was and that we needed help immediately because [X]'s hyper anxiety and my helplessness was driving me to also consider suicide as the only way out. The nurse said nothing can be done until my cases are reviewed by a psychiatrist who comes down from Perth in two weeks. I stressed how desperately we needed help now, and wasn't there any other avenue. He was adamant it was the only thing that could be done. I rang in two weeks and was told something to the effect that: It is not a high priority. After my crying and carrying on he said I could go to the local GP and get a referral which I did but there was a great waiting period. A couple of weeks later I found my husband in a farm shed covered in blood from cutting his face and wrists. He had caused no great danger to himself and after a couple of days in Harvey Hospital he was transferred to Hollywood Hospital . Three months later he succeeded in killing himself. I was so angry at having been so consistently 'fobbed off' that I went to the Mental health place in Bunbury and complained and the lady I spoke to said. "These things happen". As if it simply wasn't important.

(Carer, Wife, Western Australia , Submission #96)

My mother committed suicide on the 14th May 2002, 4 months after the birth of my eldest daughter. Mum had suffered with depression of what we think was a twenty year period, having made two previous attempts to commit suicide prior to her death. For the 4 years prior to her death we saw a consistent and notable decline in her outlook and demeanour, while receiving occasional treatment from her GP. Myself and my siblings tried so hard to help, but were always out of our depth, and growing up with a depressed mother I think made it hard for us to have a clear perspective. Mum overdosed on the anti-depressants she had been prescribed, taking 96 of them in one sitting. She had so many anti-depressant pills to take that she had a plastic box labelled with the day, each one containing 4 or 5 tablets. As I recollect, over the twenty year period, she was not offered counselling outside of her GP and all treatment seemed to be purely pharmaceutical. ... All I know is that I have a strong feeling that my mother's case was poorly managed, and the goal was always to get her through the system as quickly as possible, not to prevent her from dying.

(Son, Western Australia , Submission #87)
© Mental Health Council of Australia 2005. Last updated 29 August 2005.
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