- Email: [email protected]
Topic: Current issues in mental health service provision in Australia
Leading Opinion
Bringing the ideas and opinions of nursing leaders to the attention of nurses. We welcome your letters, comments and suggestions for this segment.
Leading Opinion Topic: Current issues in mental health service provision in Australia
Professor Cobie J Rudd RN PhD MPH BHSc(Nursing) School of Nursing, Midwifery and Postgraduate Medicine, Edith Cowan University, Western Australia
Australia has made a commitment under international human rights law to provide the highest attainable standard of mental health care. However there are significant deficiencies in the current system (Mental Health Council, 2005). The National Mental Health Report (Department of Health and Ageing, 2005) identified that mental disorders are responsible for an estimated 11% of disease burden worldwide, and the World Health Organisation predicts that this will rise to 15% by the year 2020 (World Health Organisation, 2001). In 1999, the Australian Institute of Health and Welfare reported mental disorders as the third leading cause of overall disease burden within Australia, ranking after heart disease and cancer respectively (Mathers, Vos & Stevenson, 1999). This national study found depression to be the top-ranking cause of non-fatal disease burden in Australia, causing 8% of the total years lost due to disability in 1996 (Mathers, Vos, Stevenson & Begg, 2000). Some states in Australia, have conducted burden of disease projections that see mental health problems taking over from the previous health priorities. For example, estimates from the Department of Health Western Australia in 2005 show that by year 2016, the burden of disease for psychosocial illness in Western Australia will surpass that of cardiovascular disease (Nowrojee, Codde, Geelhoed & Somerford, 2005). Similarly, the burden of dementia will increase for both sexes, and, for women in Victoria, dementia is predicted as surpassing ischaemic heart disease as the largest cause of ill health in 2016 (Vos & Begg, 2000). Looking back in time, in 1992 the National Mental Health Policy (Australian Health Ministers, 1992) heralded a program of reform that would see a more consumer focussed mental health system with the emphasis on supporting the individual in their community. Yet in 2005, mental health was again flagged as an area of special need due to significant workforce shortages in the face of growing demand (Australian Government Productivity Commission, 2005). Likewise, in 2006, the Senate Select Committee on Mental Health reported an urgent need for more mental health services and specifically, expanded community-based services (The Senate Select Committee on Mental Health, 2006a; 2006b). Why has achieving the effective provision of mental health care in the community setting founded on an inclusive tripartite relationship of care between the patient, the mental health professional, carers and community groups not yet been realised? Why are the current issues, not so much current, as continuing?
For well over a decade, changes to the funding of mental health services, mental health service restructuring, workforce reforms, consumer rights and legislation, shifting to outcomes measurement, increasing the capacity of general practitioners and the nongovernment sector’s role, and shifts to prevention and mental health promotion have been flagged as key issues. While now the implementation of State and Commonwealth frameworks for patient safety education (Department of Health, Government of Western Australia, 2005; The Australian Council for Safety and Quality in Health Care, 2005) and improved clinical education might be added to the key issues list, it would appear that effectively, very little else has changed. Whiteford and Buckingham (2005, p. 396) ask “What has happened in the last decade to get us into this situation?” They continue to suggest that the system will struggle to deliver in a climate of ever-increasing consumer and community expectations and the resultant growth in demand for services (Whiteford & Buckingham, 2005). Thus, is it a pace and extent of change issue, or should we focus less on compiling lists of the issues and more on how we might ensure better outcomes for our current investment in mental health care [a 65% increase in mental health spending since 1993 (Whiteford & Buckingham, 2005)]? While consumer and carer participation in service delivery and planning might have increased, has there been a measurable impact and outcome in terms of patient safety? Would users of mental health services report a positive shift in the clarity of standards and thus delivery of dependable services? Have the wide variations in clinical practice been addressed through the striking of new balances of trust and control between patients, professionals and government? Perhaps operationalising the safety and quality agenda in mental health care settings is critical to ensuring better outcomes. If so, a range of very specific strategies will be needed, including communicating effectively and communicating risk so that shared decision making and care is informed at least, and evidence based ideally. Identifying problems and dealing with them at a service level will require an evaluated readiness for change, the organisational tools to support consistency and accountability, and moral leadership and quality management so that research and development, professional standards, competencies, regulation and clinical governance can merge.
Collegian Vol 14 No 3 2007
3
References Australian Government Productivity Commission. (2005). Australia’s health workforce, research report. Canberra: Australian Government Productivity Commission. Australian Health Ministers. (1992). National mental health policy. Canberra: Commonwealth of Australia. Department of Health and Ageing. (2005). National mental health report 2005: Summary of ten years of reform in Australia’s mental health services under the national mental health strategy 1993-2003. Canberra: Commonwealth of Australia. Department of Health, Government of Western Australia. (2005). Western Australian strategic plan for safety and quality in health care. Perth: Department of Health. Mathers, C., Vos, T., & Stevenson, C. (1999). The burden of disease and injury in Australia, AIHW Cat. No. PHE 1. Canberra: Australian Institute of Health and Welfare. Mathers, C., Vos, T., Stevenson, C., & Begg, S. J. (2000). ‘The Australian burden of disease study: Measuring the loss of health from diseases, injuries and risk factors’. Medical Journal of Australia, 172:592-596. Mental Health Council. (2005). Not for service: Experiences of injustice and despair in mental health care in Australia. Canberra: Mental Health Council of Australia. Nowrojee, S., Codde, J., Geelhoed, L., & Somerford, P. (2005). Burden of disease: A framework for health planning? WA burden of disease study, epidemiology branch. Perth: Department of Health, Government of Western Australia. The Australian Council for Safety and Quality in Health Care. (2005). National patient safety education framework. Canberra: Commonwealth of Australia. The Senate Select Committee on Mental Health. (2006a). A national approach to mental health – from crisis to community, First report, March 2006. Canberra: Commonwealth of Australia. The Senate Select Committee on Mental Health. (2006b). A national approach to mental health – from crisis to community, Final report, April 2006. Canberra: Commonwealth of Australia. Vos, T., & Begg, S. (2000). The Victorian burden of disease study: Morbidity. Melbourne: Public Health Division, Department of Human Services. Whiteford, H.A , & Buckingham,W. J. (2005).‘Ten years of mental health service reform in Australia: are we getting it right’? Medical Journal of Australia 182(8):396-400. World Health Organisation. (2001). The World Health Report 2001: Mental health – new understanding, new hope. Geneva: World Health Organisation.
Associate Professor Nicholas G Procter RN PhD University of South Australia and Adjunct Professor, School of Health Sciences, RMIT University “One of my older sisters has had schizophrenia for over 10 years and has had the added misfortune of being ‘treated’ in a mental health care system that is totally under-funded and inadequate. The main problem with the care she has received (is) the lack of continuity. Her family have had to tell and retell a revolving army of health care professionals who are too overworked and/or inexperienced to read her bulging file, her story. What has been so devastating for me (let alone my sister) is that I have been forced to support a system that I have no confidence in, as the lesser of two evils”.
The opening paragraph is an extract from submission number 86 to the 2006 Senate Select Committee Inquiry into Mental Health. While the Australian government has through its COAG reforms sought to promote human rights, carer and consumer participation and access to services, the fundamental challenge is for all of us to ensure there is a turnaround in our system. One area where nurses can make a difference is through advocacy for continuity of care. Stepped care, for example, in which people move along a continuum of care and support from least to most intensive – and in reverse – is a way of responding to the episodic nature of mental illness. Stepped care facilitates not only better services, but also trusting, open and flexible communication in service delivery, professional roles and responsibilities, inter-agency collaboration and team building. At its base it requires strategic partnerships for dealing with the contending factors in service delivery and national mental health reform, and to learn and grow despite them.
4
Collegian Vol 14 No 3 2007
But for people to move more freely along a continuum of care there must be support for service providers. After all, the ongoing challenge will be to look beyond taken-for-granted assumptions that surround traditional practices and challenging rhetoric such as, ‘we have always done it this way’ and ‘that is the way always we do it here’. The new challenge will be practice innovation for culture change. This means knowing how and when to move in new ways, to coordinate and improve service responsiveness, focussing specifically upon role delineation, ensuring leadership is applied and interventionist and ensuring meaningful consumer participation in service delivery. The expanded role of the mental health nurse practitioner is one area where the principals of innovation are displayed in everyday practice. Such professional progress serves to strengthen personal mastery in two ways. First, it will continuously reinforce the idea that practice development is truly valued within organisations. Second, it sets the scene for individuals to respond to new and emerging opportunities. Developing personal mastery becomes a continued ongoing process that is valued within organisational culture. This analysis can be expanded to include informal networking, information and exchange and capacity building. Sometimes known as ‘relationship capital’, it can be a driver for successful organisations in their endeavour to adapt quickly to change. And for this to happen there must be human and financial resources for culture change through practice development that combine evidence based mental health care with practical learning to enhance personal coping abilities, to promote best practice, and ensure non-mental health staff become more engaged in mental health practice. Why is this important? Because staffing a modern mental health system requires an atmosphere of trust, support and encouragement to change practices for the better. There can be considerable differences of opinion surrounding professional roles and responsibilities for service delivery and diversity of expectations. The recognition, assessment and partnership management of people with mental illness in the community will require specific skills which can best be acquired through a focus on strategic alliances. This is a distinctive feature of the Brisbane based Queensland Transcultural Mental Health Centre. The QTMHC respond to the mental health needs of people from culturally and linguistically diverse backgrounds making sure that what they do is a constant symbol of the centres’ culture and values. The centre has been formally recognised for service excellence by the government of Queensland. Prompt and valuable information sharing in mental health and human services is essential to ensure continuity of care. With the same information (knowledge, really) available to everyone there is greater awareness of a common vocabulary and ways of working with fewer misunderstandings. These factors not only contribute to better clinical outcomes and prevent medical misadventure; they also drive up trust and promote partnership within and between individuals and the agencies they represent. When people talk and collaborate more freely they are more likely to trust and respect each other. And when people trust the information they receive, they are more likely to give of themselves now in anticipation of future change and reward.
Bringing the ideas and opinions of nursing leaders to the attention of nurses. We welcome your letters, comments and suggestions for this segment.
Leading Opinion Topic: Current issues in mental health service provision in Australia
Professor Cobie J Rudd RN PhD MPH BHSc(Nursing) School of Nursing, Midwifery and Postgraduate Medicine, Edith Cowan University, Western Australia
Australia has made a commitment under international human rights law to provide the highest attainable standard of mental health care. However there are significant deficiencies in the current system (Mental Health Council, 2005). The National Mental Health Report (Department of Health and Ageing, 2005) identified that mental disorders are responsible for an estimated 11% of disease burden worldwide, and the World Health Organisation predicts that this will rise to 15% by the year 2020 (World Health Organisation, 2001). In 1999, the Australian Institute of Health and Welfare reported mental disorders as the third leading cause of overall disease burden within Australia, ranking after heart disease and cancer respectively (Mathers, Vos & Stevenson, 1999). This national study found depression to be the top-ranking cause of non-fatal disease burden in Australia, causing 8% of the total years lost due to disability in 1996 (Mathers, Vos, Stevenson & Begg, 2000). Some states in Australia, have conducted burden of disease projections that see mental health problems taking over from the previous health priorities. For example, estimates from the Department of Health Western Australia in 2005 show that by year 2016, the burden of disease for psychosocial illness in Western Australia will surpass that of cardiovascular disease (Nowrojee, Codde, Geelhoed & Somerford, 2005). Similarly, the burden of dementia will increase for both sexes, and, for women in Victoria, dementia is predicted as surpassing ischaemic heart disease as the largest cause of ill health in 2016 (Vos & Begg, 2000). Looking back in time, in 1992 the National Mental Health Policy (Australian Health Ministers, 1992) heralded a program of reform that would see a more consumer focussed mental health system with the emphasis on supporting the individual in their community. Yet in 2005, mental health was again flagged as an area of special need due to significant workforce shortages in the face of growing demand (Australian Government Productivity Commission, 2005). Likewise, in 2006, the Senate Select Committee on Mental Health reported an urgent need for more mental health services and specifically, expanded community-based services (The Senate Select Committee on Mental Health, 2006a; 2006b). Why has achieving the effective provision of mental health care in the community setting founded on an inclusive tripartite relationship of care between the patient, the mental health professional, carers and community groups not yet been realised? Why are the current issues, not so much current, as continuing?
For well over a decade, changes to the funding of mental health services, mental health service restructuring, workforce reforms, consumer rights and legislation, shifting to outcomes measurement, increasing the capacity of general practitioners and the nongovernment sector’s role, and shifts to prevention and mental health promotion have been flagged as key issues. While now the implementation of State and Commonwealth frameworks for patient safety education (Department of Health, Government of Western Australia, 2005; The Australian Council for Safety and Quality in Health Care, 2005) and improved clinical education might be added to the key issues list, it would appear that effectively, very little else has changed. Whiteford and Buckingham (2005, p. 396) ask “What has happened in the last decade to get us into this situation?” They continue to suggest that the system will struggle to deliver in a climate of ever-increasing consumer and community expectations and the resultant growth in demand for services (Whiteford & Buckingham, 2005). Thus, is it a pace and extent of change issue, or should we focus less on compiling lists of the issues and more on how we might ensure better outcomes for our current investment in mental health care [a 65% increase in mental health spending since 1993 (Whiteford & Buckingham, 2005)]? While consumer and carer participation in service delivery and planning might have increased, has there been a measurable impact and outcome in terms of patient safety? Would users of mental health services report a positive shift in the clarity of standards and thus delivery of dependable services? Have the wide variations in clinical practice been addressed through the striking of new balances of trust and control between patients, professionals and government? Perhaps operationalising the safety and quality agenda in mental health care settings is critical to ensuring better outcomes. If so, a range of very specific strategies will be needed, including communicating effectively and communicating risk so that shared decision making and care is informed at least, and evidence based ideally. Identifying problems and dealing with them at a service level will require an evaluated readiness for change, the organisational tools to support consistency and accountability, and moral leadership and quality management so that research and development, professional standards, competencies, regulation and clinical governance can merge.
Collegian Vol 14 No 3 2007
3
References Australian Government Productivity Commission. (2005). Australia’s health workforce, research report. Canberra: Australian Government Productivity Commission. Australian Health Ministers. (1992). National mental health policy. Canberra: Commonwealth of Australia. Department of Health and Ageing. (2005). National mental health report 2005: Summary of ten years of reform in Australia’s mental health services under the national mental health strategy 1993-2003. Canberra: Commonwealth of Australia. Department of Health, Government of Western Australia. (2005). Western Australian strategic plan for safety and quality in health care. Perth: Department of Health. Mathers, C., Vos, T., & Stevenson, C. (1999). The burden of disease and injury in Australia, AIHW Cat. No. PHE 1. Canberra: Australian Institute of Health and Welfare. Mathers, C., Vos, T., Stevenson, C., & Begg, S. J. (2000). ‘The Australian burden of disease study: Measuring the loss of health from diseases, injuries and risk factors’. Medical Journal of Australia, 172:592-596. Mental Health Council. (2005). Not for service: Experiences of injustice and despair in mental health care in Australia. Canberra: Mental Health Council of Australia. Nowrojee, S., Codde, J., Geelhoed, L., & Somerford, P. (2005). Burden of disease: A framework for health planning? WA burden of disease study, epidemiology branch. Perth: Department of Health, Government of Western Australia. The Australian Council for Safety and Quality in Health Care. (2005). National patient safety education framework. Canberra: Commonwealth of Australia. The Senate Select Committee on Mental Health. (2006a). A national approach to mental health – from crisis to community, First report, March 2006. Canberra: Commonwealth of Australia. The Senate Select Committee on Mental Health. (2006b). A national approach to mental health – from crisis to community, Final report, April 2006. Canberra: Commonwealth of Australia. Vos, T., & Begg, S. (2000). The Victorian burden of disease study: Morbidity. Melbourne: Public Health Division, Department of Human Services. Whiteford, H.A , & Buckingham,W. J. (2005).‘Ten years of mental health service reform in Australia: are we getting it right’? Medical Journal of Australia 182(8):396-400. World Health Organisation. (2001). The World Health Report 2001: Mental health – new understanding, new hope. Geneva: World Health Organisation.
Associate Professor Nicholas G Procter RN PhD University of South Australia and Adjunct Professor, School of Health Sciences, RMIT University “One of my older sisters has had schizophrenia for over 10 years and has had the added misfortune of being ‘treated’ in a mental health care system that is totally under-funded and inadequate. The main problem with the care she has received (is) the lack of continuity. Her family have had to tell and retell a revolving army of health care professionals who are too overworked and/or inexperienced to read her bulging file, her story. What has been so devastating for me (let alone my sister) is that I have been forced to support a system that I have no confidence in, as the lesser of two evils”.
The opening paragraph is an extract from submission number 86 to the 2006 Senate Select Committee Inquiry into Mental Health. While the Australian government has through its COAG reforms sought to promote human rights, carer and consumer participation and access to services, the fundamental challenge is for all of us to ensure there is a turnaround in our system. One area where nurses can make a difference is through advocacy for continuity of care. Stepped care, for example, in which people move along a continuum of care and support from least to most intensive – and in reverse – is a way of responding to the episodic nature of mental illness. Stepped care facilitates not only better services, but also trusting, open and flexible communication in service delivery, professional roles and responsibilities, inter-agency collaboration and team building. At its base it requires strategic partnerships for dealing with the contending factors in service delivery and national mental health reform, and to learn and grow despite them.
4
Collegian Vol 14 No 3 2007
But for people to move more freely along a continuum of care there must be support for service providers. After all, the ongoing challenge will be to look beyond taken-for-granted assumptions that surround traditional practices and challenging rhetoric such as, ‘we have always done it this way’ and ‘that is the way always we do it here’. The new challenge will be practice innovation for culture change. This means knowing how and when to move in new ways, to coordinate and improve service responsiveness, focussing specifically upon role delineation, ensuring leadership is applied and interventionist and ensuring meaningful consumer participation in service delivery. The expanded role of the mental health nurse practitioner is one area where the principals of innovation are displayed in everyday practice. Such professional progress serves to strengthen personal mastery in two ways. First, it will continuously reinforce the idea that practice development is truly valued within organisations. Second, it sets the scene for individuals to respond to new and emerging opportunities. Developing personal mastery becomes a continued ongoing process that is valued within organisational culture. This analysis can be expanded to include informal networking, information and exchange and capacity building. Sometimes known as ‘relationship capital’, it can be a driver for successful organisations in their endeavour to adapt quickly to change. And for this to happen there must be human and financial resources for culture change through practice development that combine evidence based mental health care with practical learning to enhance personal coping abilities, to promote best practice, and ensure non-mental health staff become more engaged in mental health practice. Why is this important? Because staffing a modern mental health system requires an atmosphere of trust, support and encouragement to change practices for the better. There can be considerable differences of opinion surrounding professional roles and responsibilities for service delivery and diversity of expectations. The recognition, assessment and partnership management of people with mental illness in the community will require specific skills which can best be acquired through a focus on strategic alliances. This is a distinctive feature of the Brisbane based Queensland Transcultural Mental Health Centre. The QTMHC respond to the mental health needs of people from culturally and linguistically diverse backgrounds making sure that what they do is a constant symbol of the centres’ culture and values. The centre has been formally recognised for service excellence by the government of Queensland. Prompt and valuable information sharing in mental health and human services is essential to ensure continuity of care. With the same information (knowledge, really) available to everyone there is greater awareness of a common vocabulary and ways of working with fewer misunderstandings. These factors not only contribute to better clinical outcomes and prevent medical misadventure; they also drive up trust and promote partnership within and between individuals and the agencies they represent. When people talk and collaborate more freely they are more likely to trust and respect each other. And when people trust the information they receive, they are more likely to give of themselves now in anticipation of future change and reward.