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Disability Rights: Not for Service - Report: Part 6_7

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

6.7 NORTHERN TERRITORY

ANALYSIS OF SUBMISSIONS AND CONSULTATIONS FROM THE NORTHERN TERRITORY AGAINST THE NATIONAL STANDARDS FOR MENTAL HEALTH SERVICES

In summary, information presented in this section was gathered from 8 submissions (see Appendix 8.3.7) and presentations made at community forums attended by approximately 130 people (see Appendix 8.1). A draft copy of this report was sent to the Chief Minister and Minister for Health for comment. No response was received from the Northern Territory Government to the draft report; however a submission from the Department of Health was received during the consultations (reproduced in Appendix 8.4.7) and an overall review of mental health service delivery in the NT is contained in Part 2.7.7.

6.7.1 NMH 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:

  • lack of advocates;
  • information is not being provided about mental illness, treatment or rights;
  • fear of reprisal if a complaint is lodged; and
  • a lack of interpreters.

6.7.1.1 Lack of advocates

Concern was raised that no specialist advocate was available for many consumers seeking such support in Central Australia. Standard 1.6 States that: 'Independent advocacy services and support persons are actively promoted by the MHS and consumers are made aware of their right to have an independent advocate or support person with them at any time during the their involvement with the MHS.' Additionally, for consumers admitted for inpatient care, Standard 11.4.E.6 states 'As soon as possible after admission, the MHS ensures that consumers receive an orientation to the ward environment, are informed of their rights in a way that is understood by the consumer and are able to access appropriate advocates'.

There is no specialist advocate for people in Central Australia for people with a mental illness. 30% of our case load are people with a mental illness.

(Service Provider, Northern Territory, Alice Springs Forum #16)

6.7.1.2 Information not provided about mental illness, treatment or rights

Standard 1.8 states: 'The MHS provides consumers and their carers with information about available mental health services, mental disorders, mental health problems and available treatments and support services.' Reports from the community and service providers indicate this does not always occur. This is of serious concern as this failure can impact on many levels with regards to consent, choice, the right of a person to know about their illness and the treatment plan (and any side-effects) and for carers to be informed regarding what is and will be happening and how they best support the consumer or access support for themselves. It is possible these reports also suggest that consumers and carers had not been provided with a written or verbal statement about their rights and responsibilities as soon as possible after entering the MHS (Standards 1.2 and 11.4.E.6) in a manner that was understandable (Standard 1.3 and 11.4.E.6).

You're lost in space - you pick up bits of information as you go along.

(Service Provider, Northern Territory, Darwin Forum #26)

Early in his illness I wasn't aware I could be so vocal.

(Carer, Mother, Northern Territory, Darwin Forum #4)

6.7.1.3 Fear of reprisal if a complaint is lodged

Concern was expressed that many consumers and carers are not making complaints as they were afraid that services would be withdrawn if a complaint was lodged. To support this, a service provider who runs a complaint service remarked that few complaints were received regarding mental health service delivery.

This would imply that the complaints procedures were not easily accessed, responsive and fair (Standard 1.10), or that consumers and carers do not have faith in this process. Failure to have in place a system which allows patients and 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). This does not allow for the identification of single or systemic failures and thereby does not allow for personal redress or systemic improvement.

95 per cent of the reason why you don't get complaints - because they are exhausted and afraid of vindication.

(Anonymous, Northern Territory, Darwin Forum #27)

We run a complaint service, but receive not a lot of complaints about mental health.

(Service Provider, Northern Territory, Darwin Forum #25)

I was reluctant to lodge a complaint about the Top End mental health system because they were the only ones who were prepared to do anything. My son is not here speaking today. I did approach the community visitors program but my son is now in the judicial system so no one can go near him.

(Service Provider, Northern Territory, Darwin Forum #26)

6.7.1.4 Lack of interpreters

For people who have a hearing impairment or speak a language other than English, access to mental health care is further complicated by communication and cultural barriers. These barriers may make it difficult for the consumer and their family and carers to understand 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 an interpreter for reasons of confidentiality or stigma.

Concern was expressed by the Melaleuca Refugee Centre that many consumers from a non-English speaking background (NESB) are unable to access skilled and experienced interpreters and therefore language and cultural barriers are not being overcome. An inability to access interpreters could also mean that people are not being made aware of their rights and responsibilities (unless it is provided in written form) as required by Standard 1.3 (written material in their language or via and interpreter):

Language and cultural barriers are often not overcome because skilled and experienced interpreters are not available. Also interpreters will often have to play a role as a bi-cultural worker, to bridge the gap in cultural understanding.

(Melaleuca Refugee Centre, Northern Territory, Submission #191)

6.7.2 NMH 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:

  • inadequate treatment and support services to ensure the safety of consumers;
  • carers and the community;
  • the MHS is not communicating vital information with other accommodation service providers to ensure the safety of staff and other residents; and
  • transport of consumers in a manner which is not 'safe and dignified'.

6.7.2.1 Inadequate treatment and support services to ensure the safety of consumers, carers and the community

Standard 2.3 states: 'Policies, procedures and resources are available to promote the safety of consumers, carers, staff and the community.' Concern was expressed that the MHS is not providing sufficient support to guarantee this safety. In one report, the MHS failed to keep contact with a consumer and her family as arranged even when they had assessed her life and her children's life as being at risk. Other reports indicate lack of after hours support to ensure the safety of the consumer, staff and other residents in a hostel, and inability to access treatment and support resulting in a member of the community being harmed.

...During an acute and particularly traumatic episode, [X] made an agreement with mental health services that the service would contact [X]'s the family on the weekend. According to [X], despite this assurance, no contact occurred either on the weekend or thereafter.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

If a client has an episode after hours it is difficult to get assistance even via the phone. Residents and other staff can be put at risk during these times. If assistance is unavailable for some time there is a concern that it may have a flow on effect to other residents.

(Supported Accommodation Service Provider, Northern Territory, Submission #217)

There was a person turned away from the hospital because they were told he was only looking for a bed for the night. He then went out into the community and harmed somebody.

(Anonymous, Northern Territory, Alice Springs Forum #21)

6.7.2.2 MHS not communicating vital information with other accommodation service provider to ensure safety of staff and other residents

A supported accommodation service provider expressed concern that due to a lack of access to information, their own limited resources and low staff to resident ratio, they are often placed in a difficult situation of potentially having to turn away a resident if they suspect there is a level of risk to the safety of the consumer, staff or other residents.

We are concerned that we may be seen as discriminating if we turn away a mental health patient when we don't know all the details and suspect that to have that person staying in the facility may cause a danger to staff and other residents. .There is a very fine line between duty of care to current residents and staff and that of a potential resident.

(Supported Accommodation Service Provider, Northern Territory, Submission #217)

6.7.2.3 Transport of consumers in a manner which is not 'safe and dignified'

Standard 2.3 states: 'Policies, procedures and resources are available to promote the safety of consumers, carers, staff and the community'. Included in the notes to this Standard is 'policy on the transport of consumers from one location to another in a safe and dignified way'. Concern was expressed regarding the need to chemically and physically restrain people in order for them to access treatment and support services. Due to the current distribution of resources in the Northern Territory, this requirement has a disproportionate impact on Indigenous people. Concern was also raised with the need to be transported in the back of a police paddy wagon to access care.

Generally if a person's level of distress is of such concern to the clinic staff, themselves, family and / or community, the person will be evacuated, generally by air, to Alice Springs for assessment. The distances involved and the use of planes mean that evacuation to the acute service often requires chemical and/or physical restraint. Clearly there are significant safety issues that are evaluated in each case, however it does mean that Anangu are more likely to be chemically and physically restrained during an acute episode.

(Anonymous, Northern Territory, Submission #271)

I'm a manager of a hostel. We're in contact with the mental health service every day but the problem is in after hours. We seem to come unstuck. We have to try to get the person to the hospital. There is a poor response from police. The police do get some training but usually the transport occurs in the back of a paddy wagon. Only one worker on shift at night and if they do a home visit at night ...

(Service Provider, Northern Territory, Darwin Forum #15)

6.7.3 NMH 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:

  • lack of progress and consultation fatigue.

6.7.3.1 Lack of progress - consultation fatigue

Carers expressed concern that they are tired of participating on committees and attending forums and consultations to no avail. In particular, one carer was concerned that consumers and carers are risking exposing themselves by repeatedly retelling their stories and airing any grievances. Standard 3.2 states: 'The MHS undertakes and supports a range of activities which maximise both consumer and carer participation in the service'.

My son and I have been involved with the Mental Health Association and been on lots of committees and attended many forums and consultations and where are we?

(Carer, Mother, Northern Territory, Alice Springs Forum #13)

We say if you help the consumer, you help us. We have lobbied, we've written to everyone but the majority of the money has gone to the hospital not to the consumer in the community.

(Carer, Mother, Northern Territory, Alice Springs Forum #13)

This is the fourth community forum, report for mental health services in the NT - we are exposing ourselves.

(Carer, Mother, Northern Territory, Darwin Forum #2)

The Mental Health Program, Department of Health and Community Services, suggests that involvement by consumers and carers has increased:

Increased Carer and Consumer Involvement: The Mental Health Coalition has now been endorsed as the mental health peak body in the Northern Territory. Funding has been allocated to support the work of the Coalition, including coordination of mental health promotion activities. A representative from the NT will take a seat on the Board of the Mental Health Council of Australia (MHCA), the National Peak Body. The Coalition will work together with the Northern Territory Consumer Advisory Group to increase consumer and carer representation. The NTCAG was one of the earliest to be established under the National Mental Health Strategy and has representation on such committees as the Approved Procedures and Quality Assurance Committee and The Mental Health and Police Liaison Committee and provides consumer and carers representation on selection panels for mental health appointments. Consumers and carers have also provided active participation in 2003/04 within the Top End and Central Australia Service Improvement Projects.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

6.7.4 NMH 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:

  • high levels of stigma; and
  • discrimination in employment settings.

6.7.4.1 High levels of stigma

My grandson feels he shouldn't live because he has no hope for job or marriage.

(Carer, Grandmother, Northern Territory, Darwin Forum #8)

Carers and advocates continue to express concerns about the high level of stigma and ostracism still being experienced by people with mental illness. This would indicate that campaigns and activities to address community acceptance and reduce stigma to date (Standard 4.1) have not been able to turn community attitudes around. As described below, perceived discrimination and lack of community acceptance are key barriers to people with mental illness accessing treatment and support and being able to participate socially, economically and politically in society. Lack of access to services also contributes to the high levels of stigma associated with mental illness due to people having to reach crisis point before they can access services:

Admission to mental health facilities or contact with mental health professionals results in fear of consequences for community and professional standing and this fear has a realistic base.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

A Student studying in a highly professional area is admitted to the one available acute care facility and is concerned about the impact this will have on their future professional standing. The Government database is currently a shared resource. Available confidential counselling avenues are limited without extensive financial family support.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

My daughter is also ill but she's afraid of the diagnosis.

(Carer, Grandmother, Northern Territory, Darwin Forum #8)

Stigma is a persistent issue in the NT. Some of the local media have repeatedly reported on anti-social behaviour by Aboriginal and Torres Strait Island people with mental illness in a way which blames those affected, rather than relate this to symptoms and lack of treatment, as they would with any other illness.

(SANE Australia, National, Submission #302)

6.7.4.2 Discrimination in employment settings

Employment and a supportive workplace are seen as key factors in preventing the rapid escalation of mental illness and essential in the process of rehabilitation and reintegration into society after a period of illness. In support of this, Standard 4.2 states: 'The MHS provides understandable information to mainstream workers and the defined community about mental disorders and mental health problems'. However, acceptance and understanding of mental illness seem to be lacking in the workplace and, according to one presentation made by a mother at the Darwin Forum, discrimination and high levels of stigma are still prevalent as her daughter was asked to leave upon return to work after a period of illness and recovery.

There is discrimination in employment. You become ill, get the treatment on sick leave, get well again and are asked to leave.

(Carer, Mother, Northern Territory, Darwin Forum #5)

6.7.5 NMH 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:

  • policies regarding privacy and confidentiality hindering communication with carers; and
  • problems with access to databases and confidentiality.

6.7.5.1 Policies regarding privacy and confidentiality hindering communication with carers

Carers expressed concern that the policies and procedures to protect the confidentiality and privacy of consumers are hampering communication between consumers, carers and clinicians in the provision of treatment and support and potentially jeopardising the safety of consumers. Carers expressed feelings of frustration that some clinicians were very resistant to discussing anything with them.

There is lack of consultation with carers under the guise of confidentiality.

(Carer, Mother, Northern Territory, Darwin Forum #2)

Because of client confidentiality I wasn't allowed to know about my son's accommodation.

(Carer, Mother, Northern Territory, Darwin Forum #21)

6.7.5.2 Problems with access to databases and confidentiality

Although Standard 5.4 states: 'Consumers give informed consent before their personal information is communicated to health professionals outside the MHS, to carers or other agencies or people', one consumer was worried about confidentiality, and potential discrimination, as a result of people who have authorised access to the database discovering their information.

A Student studying in a highly professional area is admitted to the one available acute care facility and is concerned about the impact this will have on their future professional standing. The Government database is currently a shared resource. Available confidential counselling avenues are limited without extensive financial family support.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

A supported accommodation service provider expressed concern that they were not given sufficient information to ascertain support and safety requirements for potential consumers, current residents and staff. Such information was seen as vital due a critical lack of resources and staff in these accommodation settings. The failure to provide relevant information could result in either the consumer being turned away on the basis of perceived and not actual possible risk, or being accepted without necessary information provided to staff.

When clients are booked into the accommodation we are given no details even though at times we may be putting staff and other residents at risk. We need to have some idea of the history and any potential problems so as to be able to provide the best (even though limited) safe service possible.

(Supported Accommodation Service Provider, Northern Territory, Submission #217)

6.7.6 NMH 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 indicated concerns about:

  • the lack of focus on prevention and early intervention programs;
  • the need for joint substance abuse and mental illness treatment programs;
  • consequences of failure to intervene early and provide treatment and support; and
  • suicide prevention strategies.

6.7.6.1 Lack of focus on prevention and early intervention programs

Standard 6.8 states: 'The MHS ensures that the consumer has access to rehabilitation programs which aim to minimise psychiatric disability and prevent relapse'. Concern was expressed however that the MHS places too much emphasis on crisis intervention and too little emphasis stopping the crises from occurring by providing other programs to intervene early, prevent relapse or promote recovery.

The resources need to be outsourced from the hospital. We need respite care, prevention education for the communities: it's too chemical.

(Anonymous, Northern Territory, Alice Springs Forum #21)

6.7.6.2 Prevention - substance abuse and mental illness need to be tackled jointly

Concerns were expressed regarding the high levels of substance abuse in Indigenous communities and associated mental health issues. Concern was expressed that as these rates are so high any mental health promotions programs need to address the problems jointly. This indicates greater attention to a preventive focus in the delivery of mental health services is required, as outlined by Standards 6.4 (capacity to identify and respond to the most vulnerable consumers in the community), 6.5 (capacity to identify and respond as early as possible) and 6.6 (treatment and support to occur in a community setting in preference to an institutional setting).

Given the known consequences of substance abuse, it is alarming that treatment and support services are not provided at the earliest possible moment to prevent deteriorating illness. Result of this failure can include deteriorating physical and mental health, risk of harm to self or others, unemployment and social withdrawal, and the need for acute care in restrictive settings with severe treatment regimes.

Significant substance abuse problems exist in Aboriginal remote communities, resulting in significant mental health problems.

(Anonymous, Northern Territory, Submission #188)

...funded by the Commonwealth Government through the National Illicit Drugs Strategies to provide support for youth at risk of substance misuse. The funding provides 1.4 EFT for all Anangu Pitjantjatjara Lands communities and 1 EFT in Western Australia. This includes 22 communities and nearly all of the 350,000km catchment area of NPY lands. In one community alone there are 40 people identified as petrol sniffers. This has significant short and long-term effects on the mental health system as people misusing substances are at a much higher risk of having contact with mental health services. Clearly with the workload of these positions any ability to also look at issues of mental health prevention or ongoing support for a person with a mental health diagnosis is virtually impossible.

(Anonymous, Northern Territory, Submission #271)

Substance misuse in indigenous communities, and its associated problems, are well documented. Over the last five years the increased availability and use of cannabis on the NPY Lands has become of increasing concern to the [Y] membership.

(Anonymous, Northern Territory, Submission #271)

As the incidence of substance misuse is so high it is essential that mental health issues are addressed within this context. According to NT/SA Remote Mental Health team in 2002 half of their referrals also involved substance misuse.

(Anonymous, Northern Territory, Submission #271)

6.7.6.3 Consequences of failure to intervene early and provide treatment and support

One carer reported the consequences to the mental health of her grandchildren of services presumably not providing support to the family and the children when required.

I have mentally ill grandchildren in their 20's. My daughter is also ill but she's afraid of the diagnosis. Grandchildren are angry with us because we didn't take them out of the family home when they were young.

(Carer, Grandmother, Northern Territory, Darwin Forum #8)

6.7.6.4 Suicide prevention strategies

The Mental Health Program, Department of Health and Community Services acknowledged that the Northern Territory has a higher than national suicide rate, which is increasing, for both Indigenous and non-Indigenous residents. In response, the Department of Health and Community Services has implemented a number of specific initiatives to address suicide prevention aimed at identifying and responding to vulnerable consumers and carers (Standard 6.4). The Department noted also work working in other organisations to promote mental health and prevent the onset of mental disorders and/or mental health problems (Standard 6.3):

Care needs to be taken when interpreting suicide rates in the Northern Territory because of the relatively small numbers and yearly fluctuations. However, it is clear that the suicide rate in the Northern Territory has been higher than the national rate for the past decade and continues to rise. Indigenous suicide rates have also increased significantly. A range of specific initiatives are in place to address suicide prevention, including the Life Promotion Program which provides an integrated approach to life promotion through collaborative partnerships and community education. Key initiatives developed by the program include the Youth at Risk Network safety net, The Youth Info Card - Life Promotion Contact Card; and the Indigenous Youth Forum. Inter-Agency Suicide Response Task Groups have also been developed in the Top End and Central Australia to provide a collaborative response with the Coroner's Constables in the event of a completed suicide. They provide follow up support to people who attempt suicide, and postvention support and referral for bereavement counselling for those who have lost someone through suicide.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

In October 2003, the Northern Territory Strategic Framework for Suicide Prevention was launched. This framework acknowledges and builds on existing suicide prevention initiatives and confirms key directions and pathways for future activities.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

6.7.7 NMH 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 indicated concerns about:

  • the lack of culturally appropriate treatment and support services for Indigenous consumers and their families;
  • lack of treatment and support services for refugees and older immigrants;
  • need for training of interpreters on mental health issues; and
  • a need for additional cultural competency training for mental health professionals.

6.7.7.1 Lack of culturally appropriate treatment and support services for Indigenous consumers and their families

The unique challenges faced by the Northern Territory in providing quality mental health care were discussed by the Department of Health and Community Services.

There are also various characteristics of the Territory population that dramatically affect the demand for and cost of mental health services. The primary characteristic is that 28.5% of the Territory's population is Indigenous, compared to 2.2% in other jurisdictions in Australia. A very high proportion of the Indigenous population, 70%, live in remote areas (ABS, 2002) and English is often a second or even third language. Significant long-term primary health and environmental problems pose challenges to the delivery of mental health services to this population. Issues such as poverty, alcohol and drug misuse, domestic violence, sexual and other forms of abuse, high mortality rates as well as an increasing sense of grief and loss amongst the Aboriginal population increase the incidence of mental health problems whilst at the same time reducing individual and community capacity to respond to them. A natural consequence of this is a much higher demand for services, however, the complexity of many Indigenous issues, the need for services to be culturally appropriate and the general dispersion of the Indigenous population in the Territory, mean that it is also much more difficult to provide this services.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

Evidence presented suggests that these and other factors have acted as a barrier to the delivery of mental health care in a manner which 'considers the needs and unique factors of social and cultural groups represented in the defined community and involves these groups in the planning and implementation of services.' (Standard 7.2). Furthermore, Standard 7.3 states: 'The MHS delivers treatment and support in a manner which is sensitive to the social and cultural beliefs, values and cultural practices of the consumer and their carers' and Standard 7.4 states: 'The MHS employs staff ...with relevant experience in the provision of treatment and support to the specific social and cultural groups represented in the defined community'.

Given the considerable size of the Indigenous population in the Northern Territory and the distribution of Indigenous communities across the Territory, failure to adequately engage Indigenous communities to determine how best to meet the needs of consumers and their families in culturally appropriate ways and plan accordingly, would be a significant weakness in the ability of the MHS to promote and protect the rights of Indigenous consumers and their families.

Underlying this submission are several assumptions of knowledge: Indigenous Australians have significantly worse health outcomes than the general population, including higher rates of mental health concerns; The mental health concerns of indigenous Australians need to be viewed in the context of global disadvantage including poverty, reduced life expectancy and chronic ill health, as well as issues of cultural dislocation, trauma and grief; Anangu view mental health issues as part of a general concept that includes the health of the individual, family, community and land in a cyclic view of past, present and future.

(Anonymous, Northern Territory, Submission #271)

The issues of paranoid behaviour are difficult to deal with culturally.
(Service Provider, Northern Territory, Alice Springs Forum #9)

If the current mental health system works at its optimum level, there are still critical and serious service provision gaps. Anangu do not have access to a spectrum of interventions that are culturally appropriate and responsive to individual and / or community need. There is no access to counselling, grief and trauma support, early intervention programmes or ongoing rehabilitation programmes if someone has been diagnosed with an ongoing disability.

(Anonymous, Northern Territory, Submission #271)

As in many parts of Australian society, mental health issues are often difficult for Anangu & their families to discuss and are often only raised in relation to substance misuse. Anangu culture has many ways of supporting people at times of distress, so often help is sought only when the family's ability to care for a family member is stretched to crisis point. Ngangkari play a large role in providing ongoing mental health support in communities. They acknowledge, however, that they have little ability to deal with the effects of petrol and marijuana use.

(Anonymous, Northern Territory, Submission #271)

English is generally not the first language of Anangu families living on the NPY Lands. It can be the third or fourth language. Due to a range of factors including poor school attendance, there is a huge variation in literacy skills. Across the region literacy levels are well below the national average. The use of an interpreter is usually required, especially in the complex area of mental health, where there are often abstract and difficult concepts and choices involved.

(Anonymous, Northern Territory, Submission #271)

The indigenous community protects (hides) the mental illness until there's a crisis.

(Anonymous, Northern Territory, Alice Springs Forum #21)

However, a positive step taken by the Northern Territory Department of Health and Community Services to addressing culturally sensitive mental health care was reported.

One initiative to provide culturally appropriate mental health services is the employment of Aboriginal Mental Health Workers (AMHW). AMHWs play an instrumental role in overcoming challenges at the individual and community level by contributing to the delivery of well-informed information and interventions to Aboriginal people. They work hand in hand with mainstream mental health professionals to provide services and act as cultural brokers and mediators, as well as providing mental health assessments, management, and education at an individual, family and community level. A significant number of clinicians have also been supported to attend training programs to increase cultural competency.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

6.7.7.2 Lack of treatment and support services for refugees and older immigrants

Concern was also expressed that issues associated with migration and cultural difference need to be considered in the planning of treatment and support for older immigrants. Standard 7.1 states: 'Staff of the MHS have knowledge of the social and cultural groups represented in the defined community and an understanding of those social and historical factors relevant to their current circumstances'.

Those with a different cultural background - there's now a situation where older immigrants are now developing mental health problems and I'm not sure the services, with limited resources, respond to these problems in a small community - older immigrants are losing partners and now grieving for their home country.

(Anonymous, Northern Territory, Alice Springs Forum #11)

Melaleuca Refugee Centre works with predominantly newly arrived refugees ...from African background, Sudan, Liberia, Congo, Ethiopia and Somalia and belong to new and emerging communities. We also provide counselling for refugees who have been here longer and suffer from symptoms of Post Traumatic stress Disorder. These include people from East Timor, Indonesia, Burma, Vietnam and Cambodia. All of our clients are affected by years of trauma, loss and in some cases systematic torture. Most people suffer from some symptoms of PTSD. Some will need to access Mental Health Services. Cultural differences in the interpretation, understanding and meaning around mental health issues can form a major barrier to service provision. Western concepts of mental health are not necessarily understood and service provision might increase feelings of anxiety, disempowerment and displacement. The service provider can misinterpret symptoms or body language which might have a different cultural meaning.

(Melaleuca Refugee Centre, Northern Territory, Submission #191)

6.7.7.3 Need for training of interpreters on mental health issues

Concern was expressed by Melaleuca Refugee Centre that in order for mental health services to ensure that information is being translated accurately by interpreters, training needs to be provided to interpreters about mental health terminology and how the system works:

We rely heavily on interpreters who in most cases also come from a refugee background themselves and might not have been in Australia for a long time. Mental Health terminology and processes are usually not within their area of experience ...So far there has been no training for interpreters on mental health issues in Darwin. Melaleuca has put in a funding submission to organise such training.

(Melaleuca Refugee Centre, Northern Territory, Submission #191)

6.7.7.4 Need for additional cultural competency training for mental health professionals

Concern was expressed by Melaleuca Refugee Centre that additional training needs to be provided to mental health professionals so that they 'have knowledge of the social and cultural groups represented in the defined community and an understanding of those social and historical factors relevant to their circumstances' (Standard 7.1) and can provide treatment and support which is sensitive to the social and cultural values of people with mental illness and their family and carers:

Also training for mental health professionals on refugee issues, cultural beliefs and practices has been very minimal. There have been several meetings between Mental Health management and Melaleuca staff to address the issue, and we hope that strategies are being put into place.

(Melaleuca Refugee Centre, Northern Territory, Submission #191)

6.7.8 NMH STANDARD 8: INTEGRATION

6.7.8.1 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:

  • lack of staff and resources to provide integrated care to remote communities;
  • inability to provide coordinated care due to high staff turnover; and
  • lack of staff to provide continuity of care across sites and services.
6.7.8.1.1 Lack of staff and resources to provide integrated care to remote communities

Another factor which was seen to inhibit the provision of integrated and continuous care was the lack of staff and resources to serve the defined community, especially as in this instance, the defined community was the entire southern area of NT and SA (Standard 8.1.1: There is an integrated MHS available to serve each defined community). The following submission describes a system where a lack of staff and resources means that visits are seldom made, the focus of service delivery is predominantly crisis management and individual case planning is minimal.

Follow up is then provided by a visiting psychiatrist and two community case managers who are funded to cover the entire southern area of NT and SA. This means that the focus of the service can only be crisis management at best. The ability for workers to provide ongoing support or any meaningful individual case planning is significantly impaired. Generally the workers will average a trip once a month to the region, which means even the larger communities may not see a worker for several months. The level of service is purely resource, rather than need, driven.

(Anonymous, Northern Territory, Submission #271)

One service provider commented that Lifeline is providing support for many consumers and carers.

Lifeline is definitely aware of calls from mental health consumers and carers. The quality of the training is there and has been recognised.

(Service Provider, Northern Territory, Alice Springs Forum #14)
6.7.8.1.2 Inability to provide coordinated care due to high staff turnover

Reports of high staff turnover also concerned one carer, as this meant that there was not one designated staff member who knew the individual care plan (Standard 8.1.2) and consumers were not receiving continuous care. According to Standard 8.1.4 'opportunity exists for the rotation of staff between settings and programs within the MHS, and which maintains continuity of care for the consumer'. Also Standard 8.1.1 states: 'There is an integrated MHS available to serve each defined community'.

Many times the service didn't even know where my son was when he was in treatment. Over the years there has been a continual change in case management, every 3 months different workers, incredible turnover. There is a high case load with over 30 clients.

(Carer, Mother, Northern Territory, Darwin Forum #4)
6.7.8.1.3 Lack of staff to provide continuity of care across sites and services

With regards to Standard 8.1.5 (the MHS has documented polices and procedures which are used to promote continuity of care across programs, sites, other services and lifespan), a submission indicated problems in the ability of the MHS to provide a balanced mix of services to ensure continuity of care for the consumer due to a long wait list for the service, location problems (difficult to access with public transport) and no follow-up with the consumer or referring agency when acute care was refused.

Referral to community agencies for therapeutic counselling is primarily available through one community organisation, which has an eight week waiting list. This service is difficult to access via public transport and impacts on approximately 20 students actively seeking this service.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

[X] ... is escorted to the emergency department of the local hospital ... [Y] ... assessed [X] to be at high risk of suicide. No admission and no follow-up is arranged. Additionally, no contact was made with the referring agency and according to [X], no request of discussion with the referring agency was sought by mental health services.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

6.7.8.2 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:

  • physical health care neglected in MHS; and
  • for Indigenous people mental health care is neglected due to poor physical health.
6.7.8.2.1 Physical health care neglected in MHS

Standard 8.2.1 states: 'The MHS is part of the general health care system and promotes comprehensive health care for consumers, including access to specialist medical resources'. Concern was expressed that the MHS is neglecting the physical health of consumers. One carer stated that physical health concerns were neglected as an inpatient in the MHS and it was not until the consumer was moved to a private hospital that comprehensive care was obtainable. This means that comprehensive health care is only available to those who can afford it, resulting in people from low socio-economic backgrounds being discriminated against.

I have had an experience where I wasn't treated for a physical health problem because I had a mental illness.

(Consumer, Northern Territory, Darwin Forum #16)

I couldn't get physical health treatment for my son at same time as mental health treatment.

(Carer, Mother, Northern Territory, Darwin Forum #21)

She actually presented to the emergency department with low blood pressure. She wasn't treated and when I saw the chart it has psych patient on it. She only got treated when she was moved to the private hospital.

(Carer, Mother, Northern Territory, Darwin Forum #5)

If a person has a mental illness and other disabilities it's very difficult for them to get assistance for their physical health problems. The difficulties experienced are unacceptable.

(Service Provider, Northern Territory, Darwin Forum #6)
6.7.8.2.2 For Indigenous people, mental health care is neglected due to poor physical health

Conversely, for Indigenous people, the following submission describes poor physical health acting as a barrier to the treatment and prioritisation of mental health issues except in times of acute episodes.

It is important to note that the health providers across the region are already critically under resourced. The issues relevant to indigenous physical health outcomes are well documented. With the ongoing critical physical health needs of the community, staff are already at full capacity. In this context issues of mental health cannot be prioritised, unless there is an acute need for treatment.

(Anonymous, Northern Territory, Submission #271)

6.7.8.3 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:

  • whole-of-government approach needed;
  • higher education;
  • the lack of cross-border agreements;
  • youth; and
  • the lack of support from Centrelink.
6.7.8.3.1 Whole-of-government approach needed

I've seen the petrol babies that come into the hospital. These babies are six months old and already have brain damage. We've been told about babies that have little cans strapped to their noses because petrol babies don't cry.

(Service Provider, Northern Territory, Alice Springs Forum #17)

Concerns were expressed that the lack of services, lack of integrated service delivery, poor resource distribution and layers of economic and social disadvantage in the Territory required a whole-of-government approach to solve the complex support needs required for people with mental illness to live in the community in a dignified manner. Problems were reported with education, health, welfare, community services, disability services and housing. Many submissions identified that a broader governmental, societal and community approach was urgently required to tackle poorer health, economic and social outcomes for Indigenous Territorians, high rate of substance abuse in Indigenous communities, the high rate of Indigenous suicide and lack of support for consumers with physical disability.

We're in a crisis here in NT, particularly indigenous suicides.

(Service Provider, Northern Territory, Darwin Forum #1)

I see the end result of petrol sniffing: cognitive functioning impaired and wheel chair bound. People's behaviour is becoming challenging. Many of these people could be managed in the community and so they come into town and then require accommodation. One of the big problems is boredom. There is nothing to do; it's very sad to see five year olds sniffing petrol.

(Service Provider, Northern Territory, Alice Springs Forum #6)

There is not enough bereavement support for Indigenous people. The whole community is grieving. Good postvention is the best prevention. NT has double the suicide rate of other states. For Indigenous people there's a lack of data, but by some estimates suicide is four times the national average. Suicide amongst 15-35 years is most prominent.

(Service Provider, Northern Territory, Darwin Forum #1)

The Commonwealth Government's decision to allocate funding for the Bringing Them Home Counsellors to the Department of Health and Aged Care through the Office of Aboriginal & Torres Strait Islander Heath to the Aboriginal Health Services has caused ongoing difficulties to Link-Up Services, not only in Central Australia but also in the other states, because access to the BTH Counsellors in an appropriate service delivery model and venue has not occurred. Instead there has been a division of services. The CASG&FAC document "Where is the $63 million? Discussion Paper" explains the views of CASG&FAC [Central Australian Stolen Generations & Families Aboriginal Corporation] on this issue.

(Anonymous, Northern Territory, Submission #281)

For me this is not strong language, during the ten years I have been a carer of a severely physically disabled mentally ill person, I feel I have been treated less then human, and the person I care for, as well as others with disabilities, looked upon as worthless citizens who the governments wished didn't exist. Our loved ones are offered inferior care, if care is what it can be called. Inferior housing. Low funding to the organisations and groups in place to provide help which has resulted in overprotection of those small limited funds and a lack of wanting to work with others for fear of loosing what little money they are given, a lack of co-operation at any cost, even at the expense of the mentally ill or their carers.

(Carer, Husband, Northern Territory, Submission #68)
6.7.8.3.2 Higher education

Standard 8.3.2 states: 'The MHS supports staff, consumers and carers in their involvement with other agencies wherever possible and appropriate' and Standard 8.3.3 states 'The MHS has formal processes to develop intersectoral links and collaboration.' These Standards apply to the education sector, including schools, TAFE and universities. Links with the education sector to assist with early identification and early intervention are critical in any set of strategies targeted at prevention and gaining the skills to attain qualifications necessary for employment and participation in society. One submission indicated that insufficient supports are available for consumers to consider training and study as a serious option.

People with mental health concerns, or maybe dilemmas, who attempt to recreate or regain their lives through training and study are currently not given the support they need to do this adequately. Student support services are not able to adequately meet student's needs independently ...

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

From everything we know about mental health, prevention is one of the best interventions. But now student services are being called upon to be the 'primary' supports. This is the message from student service managers nationally.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

Several students, with ongoing mental health issues have left their studies and Darwin following many unsuccessful attempts at securing professional mental health support services locally.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)
6.7.8.3.3 The lack of Cross Border Agreements

Due to difficulties with the provision of treatment and support services to remote areas of Northern Territory, concern was expressed that access for consumers living close to the border could be enhanced through cross-border agreements with Western Australia, South Australia and Queensland. Such agreements could be used to the mutual benefit of all signatories and enhance access to scarce resources.

Lack of co-ordination between State Governments can lead to services gap and duplication. With the exception of the South Australian & Northern Territory agreement there is no coordination of services, increasing the risk of service duplication. It also means that more cost effective, co-ordinated, innovative service options are not explored.

(Anonymous, Northern Territory, Submission #271)

We want you people to listen to us & make good for us. We want family to live. We do not want to lose more people. We are still travelling to meetings and still talking same story. We do not want to send our kids to another community. We want people to come to the community & teach those kids in the bush.

(Anonymous, Northern Territory, Submission #271)

Currently, mental health services for the Northern Territory and South Australian region of the NPY Lands provided via Alice Springs regional office of the NT Department of Health. It has an inpatient service based at the Alice Springs Base Hospital and a community case management service. Geographically Alice Springs is approximately 450kms from the closest community on NPY lands. The furthest community is approximately 750 kilometres from the town (mostly on unsealed roads). The South Australian Government provides funding through its Visiting Medical Specialist program to the Remote mental health team based in Alice Springs for this cross-border region. This is one of the few examples of cross-state funding in the region.

(Anonymous, Northern Territory, Submission #271)

Anangu are affected by differences in mental health policies and funding among two States and a Territory, and the Federal Government. This includes three separate and different mental health Acts. This can be particularly difficult with issues of competency and a mobile population that moves between the three states. For example someone may have a community treatment order in Western Australia and then visit family 50 kms away in South Australia. The health service can encounter significant barriers to providing a service, especially in relation to issues of acute treatment. The borders between those two communities can mean the difference between being evacuated to Perth or Alice Springs. The incongruity of this situation raises serious and significant concerns about continuity of care.

(Anonymous, Northern Territory, Submission #271)
6.7.8.3.4 Youth

The Northern Territory also has the youngest population in Australia. Territorians under 18 make up 30% of the population, a greater percentage than anywhere else in the country. Of the 57 000 plus children in the Territory, more than 21 000, or 37%, are Aboriginal. The high number of youth in the Territory creates both challenges and opportunities for early intervention. A range of studies have also reported that young adults (18-24 years of age) have a greater likelihood of a mental disorder than older age groups. This group represents over 10% of the Northern Territory population.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

Concern was expressed regarding the paucity of services and integrated services to assist young people with mental illness, mental health problems or substance abuse problems. Such services are seen as essential from an early intervention perspective to halt spiralling negative life consequences including deteriorating health and mental health, homelessness, suicide or entry into the criminal justice system. The need to examine these issues in the context of the education system and accommodation options was also raised.

I handle a lot of crisis management youth drop-in centres, youth accommodation. Currently working with 30 young people who are chronic sniffing, we've found the best way to alleviate some of this is prevention by giving something else to do. Schools only go up to grade seven in the communities so people either board in town or don't.

(Service Provider, Northern Territory, Alice Springs Forum #8)

I've been banging on doors and writing letters. My son became ill at 15, he's now 18 and in the justice system. They're not about rehabilitation, just containment. There are no facilities for people with mental health and drug and alcohol problems. I understand what [Y] says, you get worn out. You get fobbed off. There's like a blanket discrimination. If there is nothing for kids under 18, that's a terrible scenario. My son started with a mental illness, then substance abuse - many substances, petrol sniffing - so there's blanket discrimination.

(Carer, Father, Northern Territory, Darwin Forum #3)
6.7.8.3.5 Lack of support from Centrelink

Concerns were raised with regard to carers receiving financial assistance from Centrelink and how carers can minimise bills incurred by the consumer (e.g. credit cards) that they will have to pay. With limited access to mental health services, supported accommodation and access to early intervention treatment and support, 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 by 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 adequately supported by the community.

There is a discriminatory policy that funding packages given to some families to help provide care (nothing else) for a family member with a severe disability not be allowed to be paid to blood parents or the spouse of a disabled person, as it is considered inappropriate by the funding bodies ...I am a spouse so I can't access a paid position as carer, but anyone else can even if it has been proven the job cannot be filled by anyone else. I have a package for my spouse to pay someone to help care for her, but as the months have passed it has not benefited us because I am the only one capable of caring for my spouse [X] appropriately. The paid carers, five in 18 months, have either used us or left because they couldn't cope with the situation. In the meantime we continue to live under the poverty line, while others earn money from our circumstances and invade our privacy, which lowers our feeling of self worth. I am not allowed to touch one cent of the money to help provide for my spouse's special needs and the extra associated bills. I have been told I can go and get a job while the government pays someone else the package. The package covers about four hours, five times a week. My spouse who suffers cerebral palsy, quadriplegia and schizophrenia with post trauma syndrome, is a 24-hour a day responsibility and I am still left with the bulk of the care.

(Carer, Husband, Northern Territory, Submission #68)

I and other full-time carers should be entitled to this money, as we each save the taxpayer $200,000 every year. It is discriminatory, it is unfair, and it is criminal. We are not slaves but might as well be. The Carers Payment is not help, it is an insult, and it is 25% of the average Australian's income. How can anyone live off that? The Carer Payment is the same as a Disability Support Pension, Carers should not be put on the same level of pay as pensioners, we are not pensioners but very hard workers who rarely (if at all) go on holiday or take adequate breaks from our charges. How many in the general community can say they save the taxpayer $200,000 annually?

(Carer, Husband, Northern Territory, Submission #68)

6.7.9 NMH STANDARD 9: SERVICE DEVELOPMENT

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

Under this Standard, submissions and presentations indicate concerns about:

  • the current state of service delivery in the Northern Territory;
  • carers are shouldering the burden of services which should be provided by the MHS;
  • lack of community based support or prevention focus (crisis model of care);
  • lack of resources, treatment and support services in rural and remote areas;
  • lack of skilled staff;
  • lack of funding;
  • lack of funding to NGO's;
  • staff attitudes; and
  • a greater focus needed to meet the needs of Indigenous people with mental illness and mental health problems.

6.7.9.1 Current state of service delivery in the Northern Territory

There are many stories that illustrate the lack of services and support that contribute to the continued marginalisation and disadvantage that people with a mental illness experience. The three main areas that [Y] believe are major is sue s for this region are:

•  lack of services;

•  limited service options;

•  quality of services.

(Anonymous, Northern Territory, Submission #188)

A majority of submissions and presentations made at forums in Darwin and Alice Springs conveyed feelings of immense dissatisfaction with the scarcity and low quality of treatment and support services currently available. One service provider at the Darwin forum stated that improvements have been noted. However, concern was expressed that outside of Darwin and Alice Springs access to treatment and support was extremely limited, resulting in deteriorating mental health, unnecessary use of chemical and/or physical restraint when crisis intervention was required, and potential entry into the criminal justice system.

Criminalisation of behaviour or chemical restraint - no other option.

(Service Provider, Northern Territory, Alice Springs Forum #9)

..the standard of mental health care available is minimal

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

Carers report ongoing dissatisfaction with this arrangement. They express frustration with the crisis driven care at the expense of community support and rehabilitation.

(Anonymous, Northern Territory, Submission #188)

 

[Y] described the lack of services in the following areas:

•  limited accommodation and support options exists to support people post acute care
•  the range of community based accommodation options
•  quality of life and rehabilitation options
•  consumer support
•  support groups
•  range of therapeutic treatments and exposure and training in these therapies
•  services targeted at particular groups

- children and young people
- indigenous
- older people
- NESB people

•  lack of prevention and early intervention options
•  limited service mix ...
•  quality of the services provided
•  capacity is sue for the sector - the demand exceeds supply, specifically ngo's are not able to respond due to limited capacity.

(Anonymous, Northern Territory, Submission #188)

Demand for mental health services in both community and inpatient settings increased by an average 20% in 2003/04. Rising demand may be attributed to a number of factors including increased mental health promotion activities resulting in improved community awareness, higher community expectations and a greater willingness to seek help. A decrease in bulk billing by General Practitioners may also have contributed to the increased demand for services from the specialist mental health sector.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

The Bansemer Review (2003) commissioned by the NT government found that the Territory's mental health services were 'despite the production and subsequent non-implementation of a series of reports and studies over the past decade, under-resourced, fragmented and poorly supported'.

(SANE Australia, National, Submission #302)

Positive achievements in the Northern Territory were also reported:

To its credit, the NT government has acted on the Bansemer recommendations with additional funding and a range of practical initiatives. From 2002 to 2004, the mental health budget allocation increased from $13.8 million to $25.8 million. New initiatives funded include:

•  establishment of 'step up/ step down' residential programs, to prevent the need for admission to acute wards and facilitate discharge
•  psychiatric liaison nurses for hospital emergency departments
•  four Aboriginal Mental Health Worker positions around the NT
•  appointment of a Territory Child Psychiatrist, to operate in Tennant
•  creek and Alice Springs as well as Darwin
•  some increased support for non-government organisations.

(SANE Australia , National, Submission #302)

In a submission from the Mental Health Program, Department of Health and Community Services complex factors associated with the planning and delivery of services in the Territory were noted and key achievements highlighted for the period 2003-2004. The Department also noted other initiatives designed to improve service delivery, in particular, a review of the Mental Health and Related Services Act (1998) and a Clinical Systems Improvement Project.

The Northern Territory has a range of unique characteristics that impact directly on service provision in terms of costs of services, the demand for services and the nature of services ...The estimated NT population for 2003 was 198,358 (NTDHCS) of which 68% of people reside in either the Alice Springs or Darwin Urban areas. The remaining 32% of the population live in smaller, dispersed communities, Bartlett et al (1997) note that in Central Australia, which covers an area of 1.1million square kilometres there are only two communities with populations over 800; and there are 209 communities with populations of less than 75 people. There are also numerous outstations with fluctuating populations. The Top End, which covers an area of 614,000 square kilometres, has a population of approximately 153,000 people (NTDHCS). Mental Health Services are also provided to residents in the Anangu Pitjantjatjara Yankunytjatjara Lands across the border in South Australia ...The relatively small population in the Northern Territory and the proportion of the population living in remote communities, significantly increases the complexity and costs of delivering mental health services. The tropical climate of the Top End means that access to many of the smaller communities in the NT is very limited during the wet season as unsealed roads become impassable. Outside of the metropolitan area there is also no public transport system. For those living in many communities outside of Alice Springs or Darwin, rapid access to inpatient services requires air evacuation.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

Key Achievements for 2003/04 include:

•  additional funding of $2M allocated to recruit new clinical staff, including specialist child and adolescent clinicians and Aboriginal mental health staff across the NT and to strengthen consumer and carer support in the non-government sector;

•  accreditation of the Top End Mental Health Service for two years by the Australian Council on Healthcare Standards;

•  Ministerial endorsement of the Mental Health Coalition as the mental health peak body in the Northern Territory ;

•  Ministerial launch of The Northern Territory Strategic Framework for Suicide Prevention in October 2003;

•  release of the Northern Territory Emotional and Social Wellbeing Strategic Plan in December 2003 by the Chair of the Aboriginal Health Forum The Mental Health Program played a key role in the development of the Plan, which is part of a Territory-wide effort to improve the emotional and social wellbeing of Aboriginal people; and

•  in the Top End, Mental Health Program and Commonwealth Specialist Outreach Service funding has enabled visiting psychiatrist services to commence to the Tiwi Islands and communities in the Darwin Rural, Kat herine and East Arnhem Regions. Medical Specialist Outreach Assistance Program funding has supported visits to Anangu Pitjantjatjara Lands and the Barkly region over the past 18 months.

(Mental Health Program, Department of Health and Community Services, Northern Territory, Submission #259)

A review of the Mental Health and Related Services Act (1998) is being conducted. Some of the issues that will be addressed within this review include those that relate to administrative arrangements, reporting requirements, assessment and review time lines, levels of consent, carer and family rights to information and involvement in decision-making, powers of the Court, application of community management orders in remote locations and the capacity to facilitate Interstate Orders.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

A Clinical Systems Improvement Project is also currently underway. The aim of the project is to implement and develop key quality systems, for example, Critical Incident Review, Complaints Management, case load acuity measurement and development of key performance indicators. Discharge Care Coordination Projects in TEMHS [Top End Mental Health Services] and CAMHS [Central Australian Mental Health Services] have also been established.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

6.7.9.2 Carers are shouldering the burden of services which should be provided by the MHS

Carers expressed the opinion that the model underpinning the distribution of resources and service planning needs re-examining as currently carers are being factored into the service delivery model as 'slave labour' to provide the support which should be delivered by the MHS. This model does not ensure the protection of a broad range of rights of consumers and infringes on the rights of carers to participate socially and economically in the community.

It is lame to keep blaming lack of funds. The governments drain every cent they can from carers, and use them as slave labour. Since closing the institutions carers have saved the taxpayer billions of dollars each years, but to get only a few million dollars from the governments to help stabilise a serious problem within the mental health area is like asking for pearls to be thrown before swine.

(Carer, Husband, Northern Territory, Submission #68)

6.7.9.3 Lack of community based support or prevention focus - crisis model of care

Concerns were also expressed about the emphasis on inpatient and crisis care to be provided in Darwin and Alice Springs and the neglect of community based treatments and support and early intervention approaches for consumers and their families living in remote communities.

...95% of Mental Health Services in the NT are government based and centred almost exclusively on treatment provision.

(Anonymous, Northern Territory, Submission #188)

We desperately need funding but we didn't get any of the new funding. We continue to struggle and we feel that the consumers on the ground are not benefiting from this. I feel very frustrated at the lack of insight by the Government that funding into the community will prevent increasing demand on expensive acute and crises care.

(Service Provider, Northern Territory, Alice Springs Forum #17)

I've been working at the hospital for the last couple of years. We pick up people in crisis every day, all day. We need more resources so we can help community NGO's. There's only three Indigenous workers at the hospital. We're looking for the money but where's the money? We might see a community once in 12 months.

(Mental Health Worker, Northern Territory, Alice Springs Forum #19)

It is quite interesting that 95% of the resources go to 5% of the burden. If we looked at the data we only look at hospital admissions, not where the real burden is. We need the resources to support the people in the communities who are doing the work anyway. I am actually encouraged by the strength of the response here, but we don't support people well enough.

(Anonymous, Northern Territory, Alice Springs Forum #23)

In terms of the primary health care model, we are seeing people already in crises.

(Service Provider, Northern Territory, Alice Springs Forum #3)

6.7.9.4 Lack of resources, treatment and support services in rural and remote areas

The lack of resources to deliver treatment and support services to people with mental illness in remote communities and an inability for the MHS to provide early intervention or prevention programs was a theme expressed repeatedly throughout the submissions and at both forums. Instead, claims were made that the MHS was focusing on crisis care instead of the provision of community services (early intervention) and that resources were not being allocated to reflect national mental health policies (Standard 9.14) or in manner which allows the MHS to respond promptly to the changing needs of the defined community (Standard 9.15).

Currently within Central Australia, Mental Health Services (CAMHS) provide the public sector specialist mental health service. They offer child and adolescent services, remote services, adult case management, outpatient clinics and an extended hours crisis service. Clinical services dominate in Alice Springs with CAMHS government service employing approx 46 staff members. Social and Emotional Wellbeing programs are provided by a number of Indigenous organizations. However few resources to support people with mental illness exist in remote communities.

(Anonymous, Northern Territory, Submission #188)

There is a lack of services for clients. Central Australia has a lot of unique factors - the remoteness of the area, and lack of services for remote communities, in town for community based services, accommodation, consumer support programs, recruitment of staff and retention.

(Service Provider, Northern Territory, Alice Springs Forum #1)

Core clients: 7,500. 2,000 are remote and transient. We receive about $47k from Territory Government to provide those services. There is a very low contribution from the Territory Government.

(Service Provider, Northern Territory, Alice Springs Forum #3)

Visits to remote and rural communities have become more frequent as a result of an increase in the level of clinical staff and Aboriginal Health Workers and a substantial increase in the travel budget

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

6.7.9.5 Lack of skilled staff

Lack of funding and resources, problems associated with living in remote communities and high workloads were identified as part of a package of problems in recruiting staff to fill vacancies in rural and remote areas. Lack of resources, low staff numbers allocated to cover vast geographical areas and the inability to attract and retain staff in rural and regional areas were identified as a significant problem with continuity of care (see also Standard 8.1).

Whilst the Northern Territory has traditionally been a place that has tolerated differences, the standard of mental health care available is minimal and general practitioners and mental health workers are often the primary source of medical or professional intervention available to people with mental health issues.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

Staffing levels and skills stability is a problem.

(Service Provider, Northern Territory, Darwin Forum #11)

Having developed relatively good relationships with Mental Health Services in the past, it would appear that the demand on the people employed in these services allows support to be provided in only the most reactionary way and only to those who are unable to function within the community at a very basic level ...

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

There are recruitment and retention issues in Central Australia.

(Anonymous, Northern Territory, Submission #188)

Retention of staff and the management of workloads, secondary trauma and general occupational health and safety place further stress on services. The requirements of living in remote communities and extensive, difficult travel add an extra dimension to recruiting not faced in many other parts of Australia.

(Anonymous, Northern Territory, Submission #271)

6.7.9.6 Lack of funding

Associated with the complaints of lack of available resources to deliver quality mental health services are requests and demands that the level of funding needs to change in order that appropriate services are delivered and the rights of people with mental illness are protected. Overall, funding issues were raised both with regard to Federal and State Government contributions to the health budget and the provision of support services for people with mental illness and their families and carers. A submission from the Department of Health and Community Services indicated that funding has increased to address some of the deficits identified in the delivery of mental health services:

The allocation of an additional $12.7 million between 2003-2006 to improve the mental health service system underlines the Territory Government's commitment to the mental health of the Territory's population. The mental health operational budget in 2004/05 is $20.72M, an increase of approximately $2.7M (or 15%) on 2003/04 (18M). In 2003/04, new funding was allocated to address a range of critical service system requirements including enhanced resourcing of existing services to address historical under funding. This funding provided for:

•  new clinical positions;
•  additional Aboriginal Mental Health Workers;
•  consumer and carer support in the non-government sector;
•  rehabilitation services;
•  primary health care; and
•  workforce development.

In 2004/05, an additional $1.5 million will be invested to:

•  trial sub-acute 'step-up/step down' care options which include non-clinical support provided by the non-government sector and after hours clinical services;
•  further extend non-government consumer support and rehabilitation services. The tendering process to allocate this funding has commenced;
•  further enhance child and youth mental health services; and
•  Increase visiting services to rural and remote communities.

(Mental Health Program, Department of Health and Community Services, Northern Territory , Submission #259)

6.7.9.7 Lack of funding to NGO's

Concern was also expressed about the quantity of services the MHS has contracted out to the NGO sector, or expects the NGO sector to deliver, and the inadequate level of funding provided to support the delivery of such services. The lack of certainty attached to funding agreements also contributes to the inability of services to plan and recruit staff on a long-term basis. Increased funding to the NGO sector was reported in a submission from the Department of Health and Community Services to address this deficit.

Non government services receive less then 5% of funds allocated to mental health in Central Australia and yet are the sole providers of rehabilitation and community support. Funding to Central Australia was increased by $1.5m this year however mental health NGO's did not receive any of this.

(Anonymous, Northern Territory, Submission #188)

...funding is not benefiting the consumer on the ground. Only 5% goes to NGOs on the ground. Our funding is below the national average.

(Anonymous, Northern Territory, Alice Springs Forum #18)

Most have been here for a lifetime and we receive funding for 1 year at a time. We need triennium funding. You've got to fight for that funding each year. We need continuity and consistency of our staff.

(Service Provider, Northern Territory, Alice Springs Forum #4)

Decisions are made to close viable services down because there is no money coming in, but the costs come later.

(Service Provider, Northern Territory, Alice Springs Forum #4)

The MH Association has helped me a lot. But our resources are so low we don't have the capacity to help people who really need it.

(Carer, Northern Territory, Alice Springs Forum #5)

There is a change that is coming - it looks very promising. But we get half the funding this year and we sit and wait and we don't know about next year.

(Service Provider, Northern Territory, Alice Springs Forum #20)

95% of the MH budget in the NT is for government services. 5% for non government. 7.2 million new allocation of funding. NGO's have to compete with each other for this.

(Service Provider, Northern Territory, Darwin Forum #17)

The new funding will result in an increase in the proportion of the mental health budget allocated to the non-government sector. In total approximately $910K in additional funding will be invested in the non-government sector this financial year. Grants and subsidies to Non Government Organisations (NGO) in 2004/05 will represent 10.5% of the Mental Health Operational Budget. The national average for the proportion of mental health funding to the NGO sector is 5.4% (National Mental Health Report 2002). The new funding will mean that the Northern Territory will now be above the National average in terms of funding allocated to the sector.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

6.7.9.8 Staff attitudes

Concerns were expressed about poor staff attitudes towards consumers and carers indicating that staff may be in need of training in order to change attitudes and behaviours and be more supportive when dealing with people with a mental illness. Standard 9.17 states: 'The MHS regularly identifies training and development needs of staff' and Standard 9.18 states: 'The MHS ensures that staff participate in education and professional development programs'.

First off wouldn't it be great if we could offer commitment, care and understanding.

(Service Provider, Northern Territory, Alice Springs Forum #14)

There is no sense that they want to help the consumer. I've seen things where the consumer is made to feel like they've committed a sin.

(Carer, Northern Territory, Alice Springs Forum #5)

6.7.9.9 Greater focus needed to meet the needs of Indigenous people with mental illness and mental health problems

As mentioned previously in Standard 7 (Cultural Awareness) and Standard 8.3 (Integration with other sectors), concerns were expressed that current services are not being delivered in a coordinated, integrated and culturally appropriate manner to meet the needs of Indigenous people with mental illness and/or mental health problems. This also suggests that Standards 9.7 ('the MHS regularly reviews a strategic plan which is made available to the defined community), 9.8 ('the strategic plan is developed and reviewed through a process of consultation with staff, consumers, carers, other appropriate service providers and the defined community') and 9.10 ('the strategic plan is consistent with national mental health policies and legislative requirements') may require greater attention.

Concerns were expressed regarding the failure to consider the delivery of mental health services within the broader context of poor health and social disadvantage. Submissions suggested that pilot programs and evaluation timeframes need to operate over longer periods of time for meaningful assessments to be made regarding effectiveness of program delivery. Concern was also expressed that sufficient research has been conducted in Indigenous communities and it was time to make decisions to change the model of service delivery and resource allocation.

Extreme stress on the resources available, allowing very little capacity to develop culturally appropriate and meaningful services, which are Anangu driven. Pilot funding and reporting requirements often take little consideration of the unique circumstances of the region and the length of time required to develop effective working relationships that can effect change.

(Anonymous, Northern Territory, Submission #271)

It is important to note that the health providers across the region are already critically under resourced. The issues relevant to indigenous physical health outcomes are well documented. With the ongoing critical physical health needs of the community, staff are already at full capacity. In this context issues of mental health cannot be prioritised, unless there is an acute need for treatment.

(Anonymous, Northern Territory, Submission #271)

There's a lot of funding to research mental health in indigenous communities but people were sick of being researched.

(Anonymous, Northern Territory, Darwin Forum #24)

6.7.10 NMH STANDARD 10: DOCUMENTATION

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

No submissions or comments were received pertaining to this Standard.

6.7.11 NMH STANDARD 11: DELIVERY OF CARE

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

Under this global Standard outlining the principles underlying care, submissions and presentations indicate concerns about the lack of services, implying lack of choice for consumers, carers and their families, and the inability of services to respond in a flexible manner to changing need or diverse needs for individuals. Concern was also expressed that social and cultural needs of Indigenous communities are not guiding the delivery of care to Indigenous consumers and their families.

I am writing to advocate for completely confidential services, choice of services, adequate support and flexibility to be offered in responding to mental health in the Northern Territory ...

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

Extreme stress on the resources available, allowing very little capacity to develop culturally appropriate and meaningful services, which are Anangu driven.

(Anonymous, Northern Territory, Submission #271)

6.7.11.1 Access

The MHS is accessible to the defined community.

Under this Standard, submissions and presentations indicate concerns about:

  • inability to access services, even in a crisis;
  • problems with access after hours;
  • lack of access to services in general;
  • access problems in remote areas; and
  • lack of access to care - "right to access care, not be arrested".

An inability for consumers to access treatment and support services, both within the community and inpatient care, resulted in the infringement of a whole series of rights for consumers, carers and the community. For the consumer, the infringement of these rights resulted in increasing disability and hence consequent inability to care for oneself or others, participate socially or work or study, and in some cases, the potential for harm to self or others, incarceration, or becoming homeless and poor.

Similarly, increased burdens on carers disrupted their ability to participate socially and work when their family member became increasingly ill and required increasing care. The inability to access care for their family member resulted in deteriorating mental health for carers as evidenced by the suicide attempt of one carer. Increasing disability also exposed the consumer, and their family, to discrimination and social exclusion. This often resulted in the further deterioration of the consumers' mental illness.

6.7.11.1.1 Inability to access services, even in a crisis

A constant theme of the submissions and forums was that not only were consumers unable to access services when needed throughout the course of their illness or recovery, but that access was also difficult when consumers were at risk of self harm or harm to others. According to this information Standards 11.1.4 ('the MHS is available on a 24 hours basis, 7 days per week') and 11.1.2 ('the community to be served is defined, its needs regularly identified and services are planned and delivered to meet those needs') are not being met.

Service providers and carers expressed concern that access to treatment and support is often not an option, and as a result the only options available were a restriction of the rights of consumers: i.e. entry into the criminal justice system or restraint. Comments presented also indicated increasing difficulties, rather than improvement, in the ability for consumers to access services, and that even when access was denied, for consumers at risk of self harm or harm to other, no follow-up is occurring.

Why does it have to get to an extreme before it gets looked at? ...my son is now in the judicial system so no one can go near him.

(Service Provider, Northern Territory, Darwin Forum #26)

Always, there is hanging over students in the Northern Territory, the confinement of one facility and the reality that they will only receive assistance when they can no longer control their actions.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

The hospital has gotten a lot tougher on people with a severe mental illness so it's made it hard for people to get admitted.

(Carer, Northern Territory, Alice Springs Forum #5)

It is recognised that there is a need for sub-acute care services to be developed in the Northern Territory, to provide an alternative to hospitalisation and improve transition between inpatient and community care. Tenders are currently being sought for Subacute Care trials for Mental Health consumers in the NT. The aim of this new service is to provide consumers with a time-limited, intensive level of support when they are experiencing a relapse of their mental illness. It will also provide an alternative to an inpatient admission where appropriate and facilitate early discharge from hospital. It is expected that this service will reduce the impact of an acute episode on the individual and their families and improve individual consumer choice through the options of sub-acute care in the community. Initially, the non- clinical component of sub-acute support services will be provided by NGO's through Individual Care Packages. Additional clinical positions have been funded to provide the clinical support to sub-acute care with a focus on after hours support.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)
6.7.11.1.2 Problems with access after-hours

Service providers and carers expressed concern regarding the inability to access treatment and support services after hours. As stated above Standard 11.1.4 states: 'The MHS is available on a 24-hour basis, 7 days per week'. The notes to this Standard include reference to crisis teams, extended-hours teams and 'cooperative arrangements with other appropriately skilled service providers and community agencies including General Practitioners, private psychiatrists, general hospitals'. That is, according the Standard, an appropriately skilled person should be available to assist services, consumers and carers requiring assistance after-hours.

There are no after-hours services, so people are turned away. The mental health services response is "it's because of full beds", but that's not always true.

(Service Provider, Northern Territory, Alice Springs Forum #16)

During work hours (7.6 hours per day, Monday to Friday) we receive back up and support from Mental Health Services. If a client has an episode after hours it is difficult to get assistance even via the phone. Residents and other staff can be put at risk during these times ...When a patient needs assistance, the Ambulance usually will not transport and the caller is directed to phone the police. Police will transport the client to the hospital in the back of a police wagon. This is a very degrading experience!

(Supported Accommodation Service Provider, Northern Territory, Submission #217)

[Group Y], unknown to mental health services are not able to get assistance after hours through the after hours service other than through the Accident and Emergency Department of the Public Hospital.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

Many times I have phoned up for friends after hours to services and most times you get diverted to the ward and don't get the help we need.

(Carer, Northern Territory, Alice Springs Forum #5)
6.7.11.1.3 Lack of access to services in general

Other concerns were also raised regarding access to the MHS. These included access being denied due to a lack of service options, staff attitudes or challenging behaviour (which often was the result of an inability to access services).

I found it very difficult to get into the mental health system. What we need is a variety of services.

(Consumer, Northern Territory, Darwin Forum #16)

One friend of mine thought he was somebody else and he went to the ward but was turned away so it was me and my other friends that had to put up with this person believing he was somebody else.

(Carer, Northern Territory, Alice Springs Forum #5)

Challenging behaviours - people are often turned away from the system and don't get care because of the 'behaviour problem' but often the behaviour is a result of the frustration of the consumer not getting care.

(Service Provider, Northern Territory, Alice Springs Forum #16)
6.7.11.1.4 Access problems in remote areas

The distribution of the population in small remote communities over a 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 these remote communities there are few services which could be described as 'convenient and local' (Standard 11.1.3). Access to care often involved driving long distances (for example, 5 hours to see a counsellor), contact with the police or being flown to Darwin or Alice Springs for acute care. Not only does this result in social dislocation for the consumer but reports indicated that sometimes consumers are flown to Alice Springs or Darwin and sent straight back home, presumably with minimal chances of follow-up services being arranged or available upon return.

People have to drive 5 hours to get counselling. There are some acute fly-in services but these are highly medicalised. Access to acute services requires either a flight into Alice or to Perth. Often if they are taken they are then sent out - that's it.

(Anonymous, Northern Territory, Alice Springs Forum #10)

This is the sum of mental health services provided in the Northern Territory & Anangu Pitjantjatjara lands. There is no access to counselling or ongoing support in communities. In some extreme cases people have been transported to Alice Springs to receive services from Central Australian Aboriginal Congress' (an Aboriginal health service based in Alice Springs) Social and Emotional Well Being Service for a short intensive "burst" of counselling. This model appears to work well for some individuals, however no service is funded to coordinate and fund the transport and accommodation costs required by this model. There is some provision of other diversionary social and emotional well being activities in some communities. However all of these services are significantly under resourced and sporadic across the region.

(Anonymous, Northern Territory, Submission #271)

Facilities for the treatment of acute mental illness are congregated in one area per locality in the major towns, and admission against will is often decided by specialist hook-up via Interstate video conferencing.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

The student residence caters for approximately 250 students. Many students are from interstate and without local or family supports. Each semester, on average, there are three students who require brief or long term admission to the acute care mental health facility. No contact or liaison occurs between the University and mental health services regarding ongoing support.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

The Department of Health and Community Services noted the progress of a research project to address mental health care in remote areas.

The Australian Integrated Mental Health Initiative 'AIMHI' is a National five-year research project for consumers suffering chronic mental illness. AIMHI has sites in NSW, VIC, QLD and NT. Its NT site, the remote Top End, is one of only two Indigenous sites in Australia. AIMHI NT is targeting remote Top End people with a chronic mental illness and aims to improve community-based interventions and improve the links between remote community services and urban services. To date the project has established a stakeholder network, feedback processes, an Indigenous reference group, and two Indigenous research officers.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)
6.7.11.1.5 Lack of access to care - "right to access care, not be arrested"

As mentioned previously, failure to access services when needed in some instances resulted in consumers entering the criminal justice system due to their escalating and untreated mental illness. The failure of services to respond and intervene in these instances has had the regrettable outcome of both consumers being incarcerated for the consequences of their illness and the right to safety of the community being infringed. As the majority of Indigenous people live in remote areas, this suggests higher numbers of Indigenous people with mental illness or mental health problems are represented in the criminal justice system.

People with mental health concerns and their families living on the NPY communities generally have two avenues to the mental health system: clinic staff or the police. This leads to people's mental health concerns being either medicalised or criminalised. While it is true that others in the general population may have police involvement in an admission, the lack of other services or intermediary steps greatly increase the chances of Anangu & Yanangu coming into contact with the criminal justice system, adding to their increased representation in this sector.

(Anonymous, Northern Territory, Submission #271)

6.7.11.2 Entry

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

No submissions or comments were received pertaining to this Standard.

6.7.11.3 Assessment and review

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

Under this Standard, submissions and presentations indicate concerns about:

  • the quality of the assessment and review process; and
  • assessment problems for Indigenous people with mental illness or and/mental health problems.
6.7.11.3.1 Concerns about the quality of the assessment and review process

Concern was expressed regarding the quality of assessment procedures. One carer described an incident where emergency personnel who had been called examined blood pressure and then said that the 'crisis' they had been called to attend was not an emergency and the person with mental illness and/or mental health problems was not admitted as an inpatient or assessed any further.

An ambulance was called and they take your blood pressure and then say it's not an emergency. We need a review of admission procedures.

(Carer, Northern Territory, Alice Springs Forum #5)

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'. A similar incident was reported with a referral from a service provider for a person assessed at risk of suicide:

[X] ... is escorted to the emergency department of the local hospital ...[Y] ...assessed [X] to be at high risk of suicide. No admission and no follow-up is arranged. Additionally, no contact was made with the referring agency and according to [X], no request of discussion with the referring agency was sought by mental health services.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

Another submission also referred to systemic problems associated with assessment processes.

Systemic Issues ...assessment processes for admitting client's,

(Anonymous, Northern Territory, Submission #188)
6.7.11.3.2 Assessment problems for Indigenous people with mental illness and/or mental health problems

Concern was expressed that culturally appropriate methods and tools were not available to assess risk for Indigenous youth. Standard 11.3.6 states: 'The assessment is conducted using accepted methods and tools' and Standard 11.3.10 states: 'Staff are aware of, sensitive to, cultural and language issues which may affect the assessment'. Included in the notes to this Standard is 'This is particularly important for the assessment of a person with an Aboriginal or Torres Strait Islander background'.

...Indigenous mental health. One of the most crucial things to do is to identify who is at risk and intercept. There is no culturally relevant tool in the Northern Territory for assessing risk. We need a validated tool on standardised procedures.

(Academic, Northern Territory, Darwin Forum #9)

6.7.11.4 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:

  • the lack of treatment and support services;
  • lack of services for youth;
  • lack of services for people with mental illness and intellectual disability;
  • lack of services for people with mental illness and drug and alcohol problems;
  • lack of services for people with mental illness and physical disability;
  • lack of services for people with mental illness and Acquired Brain Injury (ABI);
  • lack of services for people with Personality Disorders;
  • lack of treatment and support for consumers in the criminal justice system; and
  • carers not involved or informed with the development or review of the individual care plan.
6.7.11.4.1 Lack of treatment and support services

Many consumers and carers expressed feelings of frustration at being unable to access any treatment or support services from the MHS. This included the whole spectrum of interventions throughout the course of illness and recovery regardless of age and stage of development. Reports that services were not available until the consumer's health had deteriorated to the point requiring hospitalisation need to be considered in tandem with reports that access was often not possible even when the consumer had reached crisis point. Standards 11.4.3 - 11.4.8 state that the MHS will 'ensure' or 'provide' 'access to a comprehensive range of treatment and support services' which are specialised with regard to a person's ages and stage of development (11.4.3), stage in the recovery process (11.4.40), dual diagnosis (11.4.7) and which address 'the physical, social, cultural, emotional, spiritual, gender and lifestyle aspects of the consumer' (11.4.6). Additionally, Standard 11.4.10 states 'the MHS provides the least restrictive and least intrusive treatment and support possible in the environment and manner most helpful to, and most respectful to, the consumer'.

Clinical services leave clients till they are so unwell that they have to be hospitalised.

(Anonymous, Northern Territory, Submission #188)

Sure staff are busy but service isn't there - particularly when there is a dual diagnosis. He's referred back and forth.

(Carer, Mother, Northern Territory, Darwin Forum #2)

There is a lack of support services.

(Service Provider, Northern Territory, Darwin Forum #20)

No access to a spectrum of intervention, including whole of life span target groups. Anangu living on the NPY Lands have access only to a small range of acute mental health services whose responses are crisis driven and in circumstances where their involvement is most likely to be involuntary.

(Anonymous, Northern Territory, Submission #271)

There are some youth programs that provide diversionary activities, but they do not and cannot have a significant mental health focus.

(Anonymous, Northern Territory, Submission #271)

There are no services available for the 25 to 55-year age range beyond employment programs, whose existence and quality are inconsistent across the region.

(Anonymous, Northern Territory, Submission #271)

Lack of services for 24 - 50 year olds. This age group has no direct diversionary services working with them. Therefore with minimal employment options or further education options and high rates of substance abuse, this group is at high risk of developing mental health problems. The average age of completed suicide attempts in the Northern Territory is currently 30.9 years of age.

(Anonymous, Northern Territory, Submission #271)

TEMHS [Top End Mental Health Services] and the Royal Darwin Hospital, and CAMHS [Central Australia Mental Health Services] and Alice Springs Hospital have been selected to participate in the Mental Health Emergency Care Interface Project, auspiced by the National Institute of Clinical Studies (NICS). The aim of the project is to improve the processes of care based on best available evidence for people presenting to the emergency department with a mental health problem.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)
6.7.11.4.2 Lack of services for youth

Carers and service providers expressed concern at the paucity of services for youth and indicated that services need to be broader in their approach than treatment just for 'mental illness' as other mental health problems and family or community crises are also occurring.

In the Northern Territory, these problems are generally associated with high levels of substance abuse among Indigenous youth, starting as young as the age of five, and boredom in remote communities. 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 states that such services will address 'the physical, social, cultural, emotional, spiritual, gender and lifestyle aspects of the consumer' and Standard 11.4.7 states that, 'wherever possible, specialised in regard to dual diagnosis'. Included in the notes to Standard 11.4.7 is 'dual case management with alcohol and other drug services'.

We need a facility before we can get the youth to go. You're lost in space - you pick up bits of information as you go along.

(Service Provider, Northern Territory, Darwin Forum #26)

I see the end result of petrol sniffing, cognitive functioning impaired and wheel chair bound. People's behaviour is becoming challenging. Many of these people could be managed in the community and so they come into town and then require accommodation. One of the big problems is boredom. There is nothing to do; it's very sad to see five year olds sniffing petrol.

(Service Provider, Northern Territory, Alice Springs Forum #6)

Steps to address these problems were reported:

Child and youth mental health is a priority area for action. Some of the new mental health funding announced in 2003/04 and 2004/05 has been invested in specialist clinical positions including two child psychiatrists and three additional child and youth mental health workers. These positions will enhance expert consultancy and clinical services to young people and their families and extend service capacity to regional and remote areas across the Territory. Child Psychiatry visits to Top End communities commenced in September 2004. Child Psychiatry visits to Central Australian communities are expected to commence before the end of 2004.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

The mental health program is undertaking planning and service development work to enhance the provision of child, youth and adult mental health consultation liaison services to major urban and regional centres in order to extend capacity across the Territory. A key priority for child and youth mental health teams is to work with families and develop better links with workers in other key agencies such as schools and youth and family support services.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)
6.7.11.4.3 Lack of services for people with dual diagnosis - mental illness and 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, this includes collaborative treatment with disability services. Furthermore, Standard 11.1.1 (Access) states: 'The MHS ensures equality in the delivery of treatment and support regardless of consumer's age ...or other disability'. One service provider expressed concern that consumers with intellectual disability are being discriminated against as they are being denied treatment and support services on the basis of their intellectual disability.

People with intellectual disabilities are ignored because the Mental Health Services don't want to treat them because they say it is an intellectual disability not a mental illness, just like anyone else. I can't stress strongly enough the passing of the buck. People get put on a service merry-go-round. Some people have been to six different services and still haven't had the help they need.

(Service Provider, Northern Territory, Alice Springs Forum #7)
6.7.11.4.4 Lack of services for people with dual diagnosis - mental illness and 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'. In the notes to this Standard, this includes dual case management with alcohol and other drug services. Concern was expressed that there were an insufficient number of such services to provide treatment and support to these consumers with complex needs. Given the widespread problem of substance abuse in the Northern Territory and high association of substance abuse and mental health issues, the need for mental health services to provide treatment and support to these consumers is vital.

We see a lot of drug and alcohol and mental health issues. We're not equipped to deal with them so we outsource to Cowdry or Tamarind. The response from services is improving. A lot of work has been done by Team Health and the response has improved.

(Service Provider, Northern Territory, Darwin Forum #11)

People that have mental health problems then develop substance abuse problems, they go around in circles.

(Anonymous, Northern Territory, Alice Springs Forum #2)

We do have predominantly dual diagnosis referred because we offer more counselling. Our staff are burnt out by these people, very limited accommodation, they come in in crisis. It's the after hours care that's the major concern. When you are remote your resources are really limited.

(Service Provider, Northern Territory, Alice Springs Forum #3)

Petrol sniffing is a major problem here. Our funding is from OATSIH's [Office for Aboriginal and Torres Strait Islander Health] and one position is funded by the State.

(Service Provider, Northern Territory, Alice Springs Forum #3)

There is no single service for drugs and alcohol and mental health.

(Carer, Mother, Northern Territory, Darwin Forum #2)

Comorbid substance abuse goes hand in hand. It continues because they are longing for relief.

(Carer, Mother, Northern Territory, Darwin Forum #4)

The NT Mental Health and Substance Misuse Project which includes key government and non-government stakeholders has been established to better meet the needs of people who have a substance misuse and mental health problem. During 2004, the project will identify what services are available for people with co-occurring mental health and substance misuse problems; and provide advice on areas of need and best practice approaches that are sustainable in urban and remote Aboriginal communities. Memorandums of understanding are currently being developed and a working party is identifying screening tools for both Mental Health and Alcohol and Other Drug problems. Accredited training programs for frontline workers were held in Darwin and Alice Springs in February 2004 to increase understanding of mental illness and substance abuse issues. Further Mental Illness and Substance Abuse training targeting a broader spectrum of the workforce is planned in 2004/05.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)
6.7.11.4.5 Lack of services for people with dual diagnosis - mental illness and physical disability

Included in Standard 11.4.7 with regard to the delivery of services to people with dual diagnosis are people with 'other disability'. Carers and service providers expressed feelings of anger that consumers with physical disability were experiencing extreme difficulty in accessing services and are being discriminated against. Standard 11 (Access) states that 'The MHS ensures equality in the delivery of treatment and support regardless of ...physical or other disability' and Standard 11.1.7 states 'the MHS, wherever possible, is located to promote ease of physical access with special attention being given to those people with physical disabilities'.

For me this is not strong language, during the ten years I have been a carer of a severely physically disabled mentally ill person, I feel I have been treated less then human, and the person I care for, as well as others with disabilities, looked upon as worthless citizens who the governments wished didn't exist. Our loved ones are offered inferior care, if care is what it can be called.

(Carer, Husband, Northern Territory, Submission #68)

For Aboriginal people with disabilities ...there is not enough help, not enough funding or commitment.

(Service Provider, Northern Territory, Darwin Forum #23)

I refused treatment for depression because of possible interactions with other drugs and treatments. I am a quadriplegic - discrimination against someone with severe disability is extreme.

(Consumer & Carer, Northern Territory, Darwin Forum #7)
6.7.11.4.6 Lack of services for people with dual diagnosis - mental illness and Acquired Brain Injury (ABI)

The lack of mental health services to provide treatment and support for people with Acquired Brain Injury (ABI) was raised as a serious concern in one submission due to the current, and expected increase in, rate of substance abuse related brain injury in the Northern Territory. Currently, the Mental Health Act specifically excludes provision of treatment and support for ABI and few professionals are available to services. 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'. Furthermore, Standard 11.1.1 states 'The MHS ensures equality in the delivery of treatment and support regardless of consumer's ...physical or other disability'.

In Alice Springs there is no specialist service for people with acquired brain injury. A neuropsychologist only visits Alice Springs three times a year. This especially problematic with the Northern Territory Mental Health act being very explicit in its exclusion of people with acquired brain injury from the act. Anecdotal evidence from services providers the rates of undiagnosed traumatic brain injury and substance related brain injury are high in NPY lands. This means a significant group of people is at risk of being excluded from the few supports available, or receiving inappropriate treatment.

(Anonymous, Northern Territory, Submission #271)
6.7.11.4.7 Lack of services for people with personality disorders

Concern was also expressed that people with Personality Disorder experience difficulties in accessing treatment and support services from the MHS and frequently fall through the gaps. Standard 11.1.1 states 'The MHS ensures equality in the delivery of treatment and support regardless of consumer's ...previous psychiatric diagnosis ...or other disability' and Standard 11.4 7 states: 'The MHS ensures access to a range of treatment and support services which are, wherever possible, specialised in regard to ...other disability'.

People with Personality Disorder slip through the gaps - these people miss out and I believe their diagnosis is for 'everything else'.

(Service Provider, Northern Territory, Alice Springs Forum #16)
6.7.11.4.8 Lack of treatment and support for consumers in the criminal justice system

Standard 11.4.7 states: 'The MHS ensures access to a comprehensive range of treatment and support services which are, wherever possible, specialised in regard to ...consumers who are subject to the criminal justice system'. Concern was expressed by a mother that a comprehensive range of treatment and support services is currently not available for consumers in the criminal justice system. Under such a model of service delivery, this would indicate that little protection would be afforded to rights of people with mental illness who have become subject to the criminal justice system.

I've been banging on doors and writing letters. My son became ill at 15, he's now 18 and in the justice system. They're not about rehabilitation, just containment.

(Carer, Father, Northern Territory, Darwin Forum #3)
6.7.11.4.9 Carers not involved or informed with the development or review of the individual care plan

Despite Standard 11.4.9 acknowledging the involvement of consumers and carers ('there is a current individual care plan for each consumer, which is constructed and regularly reviewed with the consumer and, with the consumer's informed consent, their carers and is available to them'), reports were received indicating that carers are being excluded from assessment and treatment planning. Given the reported problems with access and limited services available in the community, especially for youth, practices which involve carers to assist with the delivery of care and achieve the best possible outcomes for consumers would both help recovery and protect many rights of people with mental illness.

My son is 24. He had an acute episode five years ago - he has schizophrenia. I got to read the diagnosis off the script authorisation for Olanzapine.

(Carer, Mother, Northern Territory, Darwin Forum #2)

When my son was 15 he told me he was calling the shots. It takes you straight away out of the ball park; I get very little information.

(Carer, Father, Northern Territory, Darwin Forum #3)

6.7.11.4 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 coordinate family carer services. I focus mostly on urban carers. One of our carers has been a carer for a long time and I now advise carers now to develop their own support because it's too frustrating to try and get anything from the system.

(Service Provider, Northern Territory, Alice Springs Forum #12)

Under this Standard, submissions and presentations indicate concerns about:

  • the lack of support for consumers and their families in the community;
  • lack of leisure, recreation and employment programs;
  • lack of access to family centred approaches; and
  • lack of support for children of parents with mental illness.
6.7.11.4.A.1 Lack of support for consumers and their families in the community

The aim of deinstitutionalisation 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 and support services and effective systems have not materialised for consumers living outside metropolitan areas in the Northern Territory and accommodation options are scarce.

This is true for both people with serious mental illness living in the community and people who, as a consequence of failure to access treatment and support services at the onset of illness or mental health problems, develop significant disability and require additional community support services to live independently or with their family in their communities.

Carers and service providers expressed concern that the lack of access to treatment and support services has placed considerable strain on them as carers and on their families and for parents who were carers, concern for what would happen to their children if they were not able to provide the necessary support. The lack of respite services was particularly noted.

I've been in Alice Springs since 1963, so I do know a little bit about it. Our son developed his illness when he was 28 years old. As a carer it's not easy it's very draining and frustrating.

(Carer, Mother, Northern Territory, Alice Springs Forum #13)

People are frustrated about confidentiality, a real lack of mental health specific respite beds, no day respite, no residential respite. We just have to cope with what we can because there is nothing available, no counselling for carers, no skill development for carers.

(Service Provider, Northern Territory, Alice Springs Forum #12)

My son is living away from home but if anything is wrong I am the one who gets the phone call. He wasn't diagnosed until he was 23 (he had his first symptoms at 15); he is now 30. I have seen a spiral decline over that time. As a carer there is only so much you can do.

(Carer, Mother, Northern Territory, Darwin Forum #4)

Unfortunately in Darwin there are no services in place for respite. There is nothing open over night or no day centre. There are nursing homes for elderly but not for others. Territory Health has not made resources available for carers of people with a mental illness.

(Service Provider, Northern Territory, Darwin Forum #18)
6.7.11.4.A.2 Lack of leisure, recreation and employment programs

Access to day programs to meet the needs for leisure, recreation and employment (Standard 11.4.A.4) were also reported to be declining. Access to such programs is seen as critical for consumers to reintegrate and live in the community with opportunities to participate socially and economically. Concerns were expressed regarding the lack of access to such programs and that consumers in the community 'are left dry', are bored and have no opportunity to develop any skills . Standards 11.4.A.4-11.4.A.9 ensure access to a wide variety of programs, activities and agencies to maximise the consumer's success in these endeavours. Specifically Standard 11.4.A.6 states: 'The MHS provides access to, and/or support for consumers in employment and work'.

Consumers in the community are left dry. They are put out into their flat and that's the end of it. The services we have are good but they lack staff resources and skill development. Some consumers are never given the opportunity to have rehabilitation.

(Carer, Mother, Northern Territory, Alice Springs Forum #13)

There is limited access to rehab services and lifestyle programs.

(Service Provider, Northern Territory, Alice Springs Forum #16)

I have a son who has lived with schizophrenia for 20 years. I've seen some improvements but he's also gone backwards. There is no rehab or respite. There's nothing on the weekends except for them to walk around and get into mischief.

(Carer, Mother, Northern Territory, Darwin Forum #19)

I'm really grateful for the opportunities for people with a disability to be able to work.

(Carer, Northern Territory, Alice Springs Forum #5)
6.7.11.4.A.3 Lack of access to family centred approaches

Many reports were received describing the incredible strain that has been placed on families. In particular, the lack of access to family-centred approaches and support groups was reported. 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' and Standard 11.4.A.11 states: 'The consumer has the opportunity to strengthen their valued relationships through the treatment and support effected by the MHS'. One carer described the impact of her husband's illness on her daughter, the strain on the family unit, and the lack of services to work with the family rather than individuals. The lack of access to other support services (e.g. respite, leisure, recreation, education, training, work, employment, respite, home and community care) also contributed to the strain experienced by the family.

My husband has bipolar and was sectioned in Cowdy Ward. I bashed my head against a wall for 2 years to try and get help for my husband and I was told by the MHS that I should get some counselling. I now have a 10 year old daughter who has been traumatised by this experience. My husband is getting support and so is my daughter. But there is no 'family' support to keep us together. There's a lack of early intervention.

(Carer, Wife, Northern Territory, Darwin Forum #14)

When you have a family member with a mental illness who won't acknowledge their illness, what do carers do? Do you leave children at risk?

(Service Provider, Northern Territory, Alice Springs Forum #12)
6.7.11.4.A.4 Lack of support for children of parents with mental illness

Concern was expressed that services are not responding to the needs of children of parents with mental illness who are carrying a lot of the burden. One clinician cited the needs of children whose parents are deaf and have a mental illness as access to interpreters is severely limited.

I'm concerned about children of deaf adults. My concern is that I'm probably the only interpreter from Darwin to Adelaide. Children of parents with a mental illness carry the burden. Services don't respond to children. I'm also an emotional relief counsellor.

(Mental Health Worker, Alice Springs Forum #15)

6.7.11.4.B Supported accommodation

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

Under this Standard, submissions and presentations indicate concerns about:

  • lack of housing and supported accommodation options; and
  • lack of resources and support for NGO accommodation service providers.
6.7.11.4.B.1 Lack of housing and supported accommodation options

Currently there is no interim or step down facility in Alice Springs, although apparently there are plans to develop such a service. Currently the options are the acute ward in the hospital or being flown back to the community.

(Anonymous, Northern Territory, Submission #271)

The lack of housing and supported accommodation options for people with mental illness is a serious barrier to consumers attaining the 'maximum possible quality of life' and recovering, integrating and contributing to the community. For many consumers in the Northern Territory these goals were unobtainable due to the limited services currently available and the distribution of resources and communities across the Territory. Standard 11.4.B.9 states 'Where desired, consumers are accommodated in the proximity of their social and cultural supports'. Concern was expressed regarding the limited number of services providing supported accommodation, and that as result many accommodation services operate as 'holding bays', people become homeless, or they are discharged straight back to their families with little support. The lack of step-down facilities was also noted.

There are nursing homes for elderly but not for others.

(Service Provider, Northern Territory, Darwin Forum #18)

There are three individuals living in our house with schizophrenia because of lack of other accommodation.

(Consumer & Carer, Northern Territory, Darwin Forum #7)

Some clients are evicted from mental health services. Accommodation services are lacking. Some accommodation is dormitory style, so you might have eight beds there.

(Anonymous, Northern Territory, Darwin Forum #10)

The main program is a housing program. Ranging from high support to independent - we can't deal with these kinds of problems. There are a great deal of problems with our relationship with Top End MHS but great deal of good will to address these problems. A lot of our problems would be resolved if we had a housing support worker.

(NGO Service Provider, Northern Territory, Darwin Forum #12)

Casey House Youth Refuge is the only youth refuge from here to Broome. In a crisis the mentally ill are homeless.

(Service Provider, Northern Territory, Darwin Forum #11)

Not all mental health patients are discharged to SAAP funded accommodation. Many of the clients from this group at times seem to be forgotten and slip through the net of support services.

(Supported Accommodation Service Provider, Northern Territory, Submission #217)

Non-SAAP funded accommodation facilities often end up being a 'holding bay' for clients waiting lengthy periods to access more appropriate housing. Non-SAAP funded accommodation facilities often end up being used to accommodate people who are 'unsuitable' / 'too hard' for the very sort of accommodation they are supposed to be providing for mental health clients.

(Supported Accommodation Service Provider, Northern Territory, Submission #217)
6.7.11.4.B.2 Lack of resources and support for NGO accommodation service providers

A supported accommodation service provider expressed concern with regard to the lack of support and resources available to NGO accommodation service providers. Problems included:

  • lack of funding to employ and train sufficient staff for to provide support for the range of consumers requesting admission; and
  • lack of access to MHS services to deal with crises, especially after hours.

Non-SAAP funded facilities are often unable to provide suitable accommodation as they are unable to provide adequate support.

•  Staff not trained

•  Training expenses out of reach of many organisations

•  Lack of staff

•  Residents cannot be supervised

•  Lack of social support / medical supervision

•  Lack of after hour's assistance.

(Supported Accommodation Service Provider, Northern Territory , Submission #217)

We go the extra mile in trying to provide accommodation for Mental Health Clients but are continually frustrated and concerned for both the client and ourselves at the lack of services and funding available. These are the same clients who cannot be accommodated more appropriately anywhere else.

(Supported Accommodation Service Provider, Northern Territory, Submission #217)

We would be able to provide a better service if: there was better after hours support from Mental Health Services; there was a wider range of accessible social activities and support.

(Supported Accommodation Service Provider, Northern Territory, Submission #217)

Not necessarily more agencies to provide the activities but more funding to existing ones so as to allow them to widen their horizons.

(Supported Accommodation Service Provider, Northern Territory, Submission #217)

We would be able to provide a better service if ...issues of potential violence and episodes versus confidentiality and duty of care could be addressed.

(Supported Accommodation Service Provider, Northern Territory, Submission #217)

Occupational Health and Safety along with Work Health become issues for management of a facility such as our when untrained staff are asked to work in these areas.

(Supported Accommodation Service Provider, Northern Territory, Submission #217)

There is still a great need for day-to-day support services in the community, especially affordable, appropriate supported accommodation which is in extremely short supply. As well as putting Territorians affected by mental illness at risk of homelessness, this also places additional pressure on family and other carers and on mental health workers.

(SANE Australia, National, Submission #302)

The Top End Mental Health Services have been involved in a collaborative project delivering mental health education to Supported Assistance Accommodation Program (SAAP) funded agencies. The outcome of this project has been the development of an accredited SAAP funded agency mental health training package, which is due to be released at the end of 2004.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)

6.7.11.4.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.

No submissions or comments were received pertaining to this Standard.

6.7.11.4.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 accepted therapies.
6.7.11.4.D.1 Lack of access to a range of accepted therapies

According to Standard 11.4.D.2 'The MHS provides access to a range of accepted therapies according to the needs of the consumer and their carers'. However, concern was expressed that access to such therapies in the MHS is difficult even for those who can afford to pay for such treatment in the private sector, because there are few clinicians available in the Northern Territory.

Access to the combination of pharmacological prescription and therapeutic counselling is not available to people who cannot afford to pay full private price and for those who can, remains extremely limited.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)

My husband was diagnosed with bipolar 40 years ago. He's been on and off with depression. He's been treated every time with drugs, received no cognitive behaviour therapy.

(Carer, Wife, Northern Territory, Darwin Forum #13)

6.7.11.4.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:

  • the lack of continuity of care and extreme distress for consumers and their families and carers if admission is required; and
  • transport to hospital not the most respectful.
6.7.11.4.E.1 Lack of continuity of care and extreme distress for consumers and their families and carers if admission is required

For consumers living in remote communities, the requirement for acute care posed many problems, especially as this care was generally only available in Darwin or Alice Springs. As mentioned previously, transportation to such facilities would often require the need for chemical and/or physical restraint.

Also, the lack of access to treatment and support in the earlier phases of illness resulted in consumers being in desperate need of medical, often life-saving, medical care at point of admission. Concern was also expressed that having reached this level of distress, both the consumer and their family had to endure even further strain as they were separated for the period of admission as the distances and costs involved for visits were prohibitive and public transport not available. This also complicated any continuity of care and the involvement of carers in treatment planning and support.

The inability to access care at the earliest possible moment therefore resulted in a whole series of rights being jeopardised for consumers, impacting disproportionately as previously outlined on Indigenous people. In these situations, many of the criteria under Standard 11.4.E were not met. For example: the MHS offers the least restrictive alternative (11.4.E.1), admission assessment includes the views of other current service providers and the consumer's carers (11.4.E.4), the impact of admission is minimised on the consumer's family and significant others (11.4.E.7) and consumer's visitors are encouraged (11.4.E.8). The Department of Health and Community Services indicated that some of these concerns are being addressed.

As people are often evacuated, without the support of family, relatives may have no contact with the treating team. They may not be given information or able to provide information to the treating team. If a person is admitted to hospital for a period of time the costs associated with family visits are prohibitive. In communities diesel can be up to $1.60 / litre, which means that doing 1000km round trips is beyond the capabilities of most. There is no public transport available on NPY Lands. This leads to extreme distress within families and communities.

(Anonymous, Northern Territory, Submission #271)

Issues related to patient care and staffing in the specialist Mental Health Inpatient Units are being addressed with clinical staff, union representatives and other key stakeholders. Admission and discharge policies have been reviewed. Assessments in the Emergency Department are better managed with the creation of a new mental health consultation liaison nurse position and the redevelopment of the extended hours service, with a community mental health nurse rostered to the Emergency Department after hours 7 days a week.

(Mental Health Program, Department of Health and Community Services, Northern Territory,
Submission #259)
6.7.11.4.E.2 Transport to hospital not the most respectful

Concerns were expressed regarding the use of police and police wagons to transport consumers to hospitals for treatment when this level of response was not required. It was stated that this response was 'degrading' and made young people 'lose their dignity'. Standard 11.4.E.3 states: 'The MHS ensures that a consumer who requires involuntary admission is conveyed to the hospital in the safest and most respectful manner possible'.

When a patient needs assistance, the Ambulance usually will not transport and the caller is directed to phone the police. Police will transport the client to the hospital in the back of a police wagon. This is a very degrading experience!

(Supported Accommodation Service Provider, Northern Territory, Submission #217)

These young people really lose their dignity when they are transported in paddy wagons.

(Carer, Mother, Northern Territory, Darwin Forum #21)

6.7.11.5 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:

  • the lack of services and options available to assist with discharge planning.

Systemic Issues ...quality of discharge planning.

(Anonymous, Northern Territory, Submission #188)
6.7.11.5.1 Lack of services and options available to assist with discharge planning

Concern was raised about the lack of options available to plan adequately for treatment and support of consumers after discharge. Due to the lack of supported accommodation, step-down facilities, community based treatment and support services and lack of rehabilitation services, care was seen to fall predominantly on carers.

A problem was identified for Indigenous carers that due to chronic ill health within Indigenous communities, the assumed burden must be presupposed to be high. This limited treatment options to medication only and very little overall support to the consumer. Also, the carer has generally not been present during the hospital stay to be familiar with treatment plans, exit plans and be informed about the illness and how best to support the consumer. Most criteria under Standard 11.5 would, according to concerns expressed throughout this Report, be difficult to meet. For example, the exit plan is reviewed with the consumer and their carer (11.5.2).

It also needs to be noted that due to the high level of chronic ill health within communities the burden on carers within families is often very high. Therefore it is important that health professional do not make assumptions about the level of family support available when making discharge plans.

(Anonymous, Northern Territory, Submission #271)

After the acute treatment episode people are discharged to their community. Generally they are flown home, with information for ongoing medical management by the clinic staff. This is mainly the administration of medication. Currently there is no interim or step down facility in Alice Springs, although apparently there are plans to develop such a service. Currently the options are the acute ward in the hospital or being flown back to the community.

(Anonymous, Northern Territory, Submission #271)

6.7.11.6 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:

  • the lack of follow-up.
6.7.11.6.1 Lack of engagement with consumer after exiting inpatient care

Concern was expressed that after discharge from an acute mental health facility no contact was made by the MHS to ensure the health and safety of the consumer. This could indicate that no exit plan or follow arrangements were made or that no attempts were made by the MHS to re-engage with consumers who did not keep the planned follow-up arrangements (Standard 11.6.4).

A student returns to Uni after admission in the acute care mental health facility. No contact is made from mental health services ...According to the student, no follow-up via mental health services has been offered.

(Support and Equity Services, Charles Darwin University, Northern Territory, Submission #269)
© Mental Health Council of Australia 2005. Last updated 29 August 2005.
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