CHAPTER 13 Organising care for the mentally ill in Australia
This chapter provides an overview of the delivery of mental health care in Australia. The World Health Organization (WHO) estimate that 450 million people have mental health disorders worldwide with 1 person in 4 experiencing some form of mental health problems during their life (WHO 2004: 13). In Australia, the 1997 National Survey of Mental Health and Wellbeing found that 17.7% of the population had experienced mental health problems in the last 12 months while a more recent study of people living within the community found that 10.7% had long-term mental health problems (Australian Institute of Health and Welfare [AIHW] 2007e: 4).
The last 50 years have witnessed a global change from institutional to community care in mental health systems. This change has been driven by a greater focus upon the human rights of people with mental illness and the need to reduce stigma. The United Nations (UN) released the ‘Principles for the Protection of People with Mental Illness and for the Improvement of Mental Health Care’ in 1991. This document calls for the discontinuation of discrimination and the full participation of people with mental illness in society. People with mental illnesses are entitled to the same rights as other citizens including the right to live in the community and to have care delivered in ‘the least restrictive environment and with the least restrictive or intrusive treatment appropriate to the patient’s health needs’ (UN General Assembly 1991). Australia became a signatory to the resolution, committing Australia to the goals of the resolution.
The mentally ill in Australia were initially managed within the penal system. The first asylum in Australia was built at Castle Hill, Sydney, in 1811 (Garton 1988). By 1900 there were 16 asylums in Australia, five in New South Wales, six in Victoria, two in South Australia and one each in Tasmania, Queensland and Western Australia (Coleborne 1996; Dax 1961; Fox 2003; Kay 1970; Lawrence 2002; Megahey 1993). At that time, mental illness was not regarded as a medical problem and doctors had little control over asylums. Medical diagnosis and certification of mental illness was not required by law until 1839 in New South Wales, and later in other colonies (Garton 1988). Some early asylums were run by lay rather than medical superintendents, until 1883 when a series of government inquiries into conditions in asylums called for scientific management of the mentally ill. This led to the appointment of a medical superintendent and medical control over other asylum employees (Coleborne 1996).
The growth of the number of psychiatric patients led to the building of more psychiatric hospitals. By 1953 there were 24 large-scale psychiatric hospitals in Australia, nine in New South Wales, seven in Victoria, four in Queensland, two in South Australia and one each in Western Australia and Tasmania (Stoller & Arscott 1955). A Federal government report from 1953 found that psychiatric hospitals were overcrowded and contained patients who could be accommodated elsewhere, such as the elderly or intellectually disabled. The report recommended the building of new psychiatric hospitals to manage the number of patients in the system, the provision of services in general hospital and outpatient units, and separate services and accommodation for older people and the intellectually disabled (Stoller & Arscott 1955).
Following this report, there was a movement towards earlier discharge from psychiatric hospitals. Deinstitutionalisation began in 1955 in Australia and accelerated from the late 1980s. It was based on an understanding that mental illness could be prevented by early intervention and that long-term institutionalisation had a negative impact on mental health outcomes. The first wave of deinstitutionalisation involved the establishment of community services such as state-funded day hospitals, community housing, community mental health centres and outpatient care for the newly diagnosed and the acutely ill. There was also movement of older people, people with drug and alcohol problems and the intellectually disabled into separate services. State governments also invested in the development of psychological services for children on the understanding that mental illness and criminal behaviour could be prevented through intervening when children first demonstrated disturbed behaviour. People with severe or chronic mental illness did not respond well to the available treatment and were excluded from the first wave of deinstitutionalisation.
Deinstitutionalisation accelerated from the late 1980s. This time the focus was on deinstitutionalising the chronically mentally ill and establishing community services for them to live outside of psychiatric hospitals. Also on the agenda was the movement of inpatient facilities from psychiatric hospitals to psychiatric wards in general hospitals. Movement towards these goals varied across the country resulting in the national government calling for a national mental health service policy. The National Mental Health Strategy was agreed by state, territory and Federal Health Ministers in 1992.
The National Mental Health Strategy originally consisted of three documents: the National Mental Health Strategy and first National Mental Health Plan released in 1992, and the Mental Health Statement of Rights and Responsibilities, released in 1991 (Commonwealth Department of Health and Aged Care 1998b). Two subsequent 5-year National Mental Health Plans were released in 1998 and in 2003 with another due in 2008.
The terms of reference for the National Mental Health Strategy and National Mental Health Plans are outlined in Table 13.1. The goals of the original National Mental Health Strategy were to move service delivery and funding for mental health services from psychiatric hospitals to general hospitals and the community, to create better links between government support services and non-government organisations (NGOs); and to foster uniform mental health legislation across the country. The second and third National Mental Health Plans focused on: prevention and early intervention; development of service partnerships; development of mechanisms for consumer and carer participation; research and service evaluation.
Mainstreaming describes the shift of services from stand-alone psychiatric hospitals into general hospitals. This was viewed as a means of reducing stigma and increasing access to services allowing the mentally ill to remain close to ‘family, community and cultural networks’ (Australian Health Ministers 1992: 2). Table 13.2 shows the number of psychiatric hospitals and average bed availability in those hospitals between 1989 and 2005 Australia wide. From 59 psychiatric hospitals in 1989 the number fell to 20 hospitals in 2005. Psychiatric hospitals beds also fell by 71% between 1989 and 2005 (AIHW 2000, 2007). This has been accompanied by a 41% growth in psychiatric beds in general hospitals. By 2003, 61% of all public psychiatric beds were offered within general hospitals, compared with 27% in 1993, with a 24% reduction in total psychiatric beds (Department of Health and Ageing 2005b).
|Year||Number of psychiatric hospitals||Number of available beds|
Sources: AIHW 2000, 2005g, 2007e
Pause for reflection
White and Whiteford (2006) argue that deinstitutionalisation has resulted in prisons becoming mental health institutions. They found that 7% of prisoners had a severe mental illness and that another 23% suffered from mood disorders like depression. Given this do you think we need more psychiatric beds for the mentally ill?
Community services were developed to promote individual care and the person’s dignity (Australian Health Ministers 1992). Such services range from community mental health teams which assess, monitor and maintain people in the community, to residential services such as supported accommodation, and services that provide social and employment activity. Spending on community services increased by 158% in the decade 1993 and 2003. Three-quarters of the funding was spent on ambulatory services, such as outpatient departments, clinics, mobile assessment and treatment teams and day programs (Commonwealth Department of Health and Ageing 2005b). Despite this, rural and remote regions still experience difficulties in accessing community services, due to the level of demand for specialist mental health services, the management of severely mentally ill people within their community where they can be near families and social networks, and a lack of alternate service providers such as NGOs and GPs (Gibb, Livesey & Zyla 2003). These conditions make it difficult to retain experienced mental health staff in rural areas.