On Thursday, the federal health minister, Ms Sussan Ley, announced a new framework to tackle what has been described the crisis in Australia’s mental health system. Key opinion leaders in this field from the AMA to top academics and researchers have had mixed responses to the announcement. For what it’s worth, this is mine.
I am a consultant psychiatrist working solely in private practice. I run a very busy clinic covering a wide range of clinical sub specialties and many of my patients have been coming for several years. Prior to this, I completed my training in a tertiary teaching hospital, and over 10 years have seen many patients with all forms of mental illness. I have also worked in rural and indigenous areas and have first hand knowledge of what works.
Regardless of their condition, their social situation, their background, their journey, two things help patients recover. Hope and connection.
When my patients recover they tell me they were grateful I didn’t give up on them. As they became well, they could see at the very time they were most unwell they truly believed things would never get better. So my ability to hold their fears, and reinforce with consistency and kindness that things would improve, were the most therapeutic ingredients to my package of care for them. Connection with a stable consistent provider of healthcare was paramount.
As doctors, we often forget how important we are in the care of our patients. This is particularly true in psychiatry when there are so many other ‘key stakeholders’ in the delivery of care to those with mental illness. We often relinquish our roles, shy away from leadership and stifle our voices when we see care we don’t agree with. It’s almost as if the system can only work if we remain silent. But I find that very hard to do.
For what it’s worth, I have been involved in the care of patients with all forms of mental illness since the era of deinsitutionalisation, firstly as a pharmacist and then as a psychiatrist. I have seen fundamental changes to the care they receive over the past 25 years. I liken this new round of changes to a homeopathic treatment for the mental health system.
Each time a new strategy or overhaul of care is delivered to great applause, it is as if the policy makers have diluted the pool of patients with mental illness to such a point that they focus on only the smallest fraction of those who need and deserve our care. The very small number of people who have the insight, and know how to go and seek out some help. They talk about ‘support’ ‘engagement’ ’empowerment’ and ‘resilience’ like they are evidence based measures of successful outcomes. They talk about strengthening partnerships and improving access without any tangible way of assessing what that means. The rest are diluted out and discarded.
For the past 25 years not one single mental health policy has addressed the needs of those with severe and chronic mental illness.
Over 25 years I have seen patients with schizophrenia, bipolar disorder, borderline personality disorder, melancholic depression, anorexia nervosa and many other clinical presentations be moved from pillar to post, often quickly and at the hands of a new government. Every single time this happens the two most valuable aspects of psychiatric care, hope and connection are fundamentally destroyed. The argument that ‘well this approach ain’t working, so let’s replace it’ drives this move to destroy hope and connection.
For the past 25 years not one policy has looked at what we have and tried to improve it, rather than reinvent it.
Let’s be sure of the facts, the ones that are diluted out in the homeopathic process that is labelled mental health reform;
- Many patients with severe and chronic mental illness require lifelong care and frequent hospitalization.
- Being hospitalized for mental illness is not a failure of anybody but exactly the appropriate type of evidenced based care a patient needs if acutely unwell, and at risk to themselves or others. And a long hospital stay often means a patient is very unwell, not that the services are incompetent.
- We have turned our backs on those already in long term and residential care, the very thing policy makers said they would not do when patients were turfed out of asylums. They are still here, with us, deserving of our care just as in any other severe illness, but are firmly entrenched in an overflowing ‘too hard basket’.
- We already have a mental health system which is failing not because it is hospital based, and the idea of building primary care networks for this group of patients has no merit. Patients with severe and chronic mental illness deserve multidisciplinary care that can be flexible in a ‘step up-step down’ way and can move to provide the care and risk reduction required. The reason this doesn’t work now is not because it is based in the hospital system, but because the services are so poorly run down they can’t offer what the patient needs. Administering ‘care packages’ to these patients, already known to the professionals in the public mental health system will lead to a doubling up and waste of valuable money that could be used to create extra beds and fund more staff.
- It is not the patient’s fault that they fall through the state government/federal government convenient ‘diffusion of responsibility’ construct.
- Improving knowledge and awareness of mental illness by providing fact sheets and e-health approaches are good for some but this should not be applied to mentally ill patients in a broad brush way.
There is evidence for these arguments everywhere, it’s just that the whole mess that began after deinstitutionalisation is so large now that nobody wants to talk about it. Patients who left asylums in the late 1980s moved through an era of case management, mobile support teams and crisis assessment and treatment teams. But then these services became so overwhelmed they could no longer deliver assertive outreach to the level they should. With nowhere else to turn, many became ‘frequent flyers’ in our state hospital emergency departments. When they were ready to be discharged from hospital, there was no room at the chronic care units if they needed it. NGO’s that provided wonderful support and consistency such as Richmond Fellowship and St Mary’s House of Welcome suffered massive funding cuts. And rather than improving medical comorbidity in patients with mental illness, mainstreaming psychiatric services into major teaching hospitals has led to more stigma and a sense that patents with mental illness are purely bed blockers.
There is so much devil lying in the detail of this new mental health reform. It is also very disappointing that it was announced without any increase in funding for the public mental health system, and in top of that, Medicare cuts for patients with severe and chronic mental illness. I have many questions about this implementation of primary health networks (PHN’s) and it is hard to ascertain any information. In particular, I wonder who will be staffing these organisations, to what level of acuity can they provide care, and how does a patient and a health professional interface with a PHN? What will be the role of the GP, the one who should be the cornerstone of medical care for all patients? How does the private psychiatry and psychology system fit with this? How long will PHN’s be around for and what happens to the patients after the funding runs out? Allow me to be cynical because I have seen it all before. I work every day with patients with mental illness, I wear all the responsibility and I know how complicated it can be.
So what do I think we need? Well, it’s not that glamorous, and doesn’t contain a lot of rhetoric, so it probably won’t get up. But I reckon after 25 years in this area of medicine I might be onto something. My simple recipe for mental health reform (totally undiluted):
- Allow psychiatric triage services that exist in all our major hospitals across Australia the resources and staffing to be able to pick up the phone and respond when a patient is in crisis. These clinicians often know the most unwell and vulnerable patients in their network. They have managed them for years. The know what they are doing. And they have a connection with them.
- Boost the crisis teams and assertive outreach teams, bring back the homeless teams and all the wonderful services that could respond in a timely and safe manner.
- Look after staff who dedicate their careers to helping some of the most disadvantaged people in our society, so they remain in the system and continue the connection.
- Have places of haven for those who live with symptoms all the time. Be kind to them.
- And above all, invest in acute services that know exactly how to manage mental illness and have been doing so for years.
Bring hope and connection back to the forefront of what we are trying to achieve. Not another layer of bureaucracy and more strangers that may come and go in and out of a patient’s life.
Dr Helen Schultz is a consultant psychiatrist and advocate of patients with mental illness. She is also passionate about doctor’s mental health, and attracting doctors to the wonderful profession that is psychiatry. She is the author of How Shrinks Think.