Australia’s mental health system in distress

In October, 2005, the Mental Health Council of Australia and the Brain and Mind Research Institute, in consultation with the Human Rights and Equal Opportunity Commission of Australia (HREOC), published a damning report into the state of Australia’s mental health system, entitled ‘Not for Service: Experiences of Injustice and Despair in Mental Health Care in Australia’. The report echoes assertions from mental health practitioners that Australia’s mental health system is in crisis. 

Australia is party to two international covenants affirming “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health,” – the International Covenant on Economic Social and Cultural Rights and the Convention on the Rights of the Child. The recent report demonstrates the fallacy of Australia’s commitment to fundamental human rights in the mental health system and its failure to address issues of concern. 

Unlike previous reports from the HREOC on mental health, the primary purpose of the current report was to capture personal stories from within the mental healthcare system. The report, while basing its framework on the National Standards for Mental Health Services as outlined by the Commonwealth Government in 1996, did not aim to prove or disprove the successful implementation of those standards. While information tended to do so, the purpose of the report was to cumulate personal and individual experience of Australia’s health care system from consumers, carers and professionals.  

Not for Service demonstrates that the human rights violations in the mental health system exposed in HREOC’s 1993 report (the Burdekin report) have not been redressed. While on paper the rights of the mentally ill appear to have improved, the reality is quite the contrary. The report reveals an ongoing inadequacy of measures to deal with mental health patients. “The stories told during these consultations and surveys by mentally ill persons and their families suggest a pattern of continuing neglect,” the report states. “It seems that, even where there has been good policy or law, the policy has not been translated into reliable, high quality health care.”  

The 1993 Burdekin Report emphasised the problems relating to institutionalisation of the mentally ill. This sparked a move towards de-institutionalisation, with the aim of improving the spectrum of care services available and improving cost efficiency. As such, much of the work of the national mental health reform process in Australia has concentrated on moving the focus of care from institutions to community settings. What this most recent report notes is that such moves have not solved the multiple rights issues facing the mentally ill. ‘Movement away from a hospital-base has meant that hospital-based services are now in short supply.’ In itself, this would not be problematic, the idea being that community services would take up the slack left by a lack of institutional places. However, “community services and related workforces have not expanded sufficiently to meet the increased demand and the relative needs for increased expenditure on mental health seem to have lost out to the other traditional hospital-based and procedural areas of medicine.” As such, there is a distinct lack of care provided in the community for individuals now out of institutions. The result is “arguably a sub-standard system of semi-institutionalisation within the community that lacks many of the best features of the old system.”  

As the report points out: “While there is a lot to be said for preferring community treatment over institutional treatment, we cannot assume that community treatment is actually being effectively delivered. Just releasing mentally ill men, women and children into the community without appropriate supports is not an adequate reaction to the problems arising from institutionalisation.”  

The report highlights the “fundamental inequity” in health care expenditure allocation in Australia. While funding for physical illnesses, such as respiratory disorders and cancer is linked to the disease’s term and severity, funding for mental illness is limited to short-term care, leaving those with recurrent or chronic disorders vulnerable and suffering. Mental health is not resourced appropriately relative to its disease burden of the availability of effective treatments. Mental health patients are often unable to access adequate care, particularly in remote areas and even if access is available, it is often expensive and beyond the means of many individuals. Overloaded caseworkers are unable to give due attention to the long-term needs of their clients. Shortages mean that mental health practitioners refuse to carry out early intervention until the person is ‘acutely’ unwell, leading to forceful intervention. Thus, patients are not kept well, risks are not minimised and disorders are not averted when they ostensibly could be. Preventable deaths are occurring as a result of this lack of services, a situation that is incompatible with human rights and economically unsound.  

Even in times of crisis, anecdotal evidence suggests that patients are not admitted or are discharged early due to an inability to access an available inpatient bed. Reduced access to care has been linked to higher rates of post-discharge suicide. A failure to provide decent health services also results in encounters with the criminal justice system, with individuals ending up in jail instead of in treatment due to a lack of resources. A lack of adequate community care has resulted in a new form of institutionalisation: homelessness and imprisonment. Of particular concern is the absence of proper care and facilities for young people in spite of research suggesting that 75 percent of mental illness first occurs in people aged between 15 and 24 years of age. 

Moreover, the distinction between physical and mental illnesses appears to run beyond resource allocation. Surveys and submissions indicated that those individuals with mental illness and their families were commonly shown a lack of respect, poor resources and inadequate facilities, combining to make the mental health services less safe than the rest of the health system. The stigma associated with mental illness result in wide variations in care between medical and mental health services, with an emphasis on the ‘containment’ of mental disorders, rather than treatment.  

While Commonwealth, State and Territory governments report, as in previous years, that work is underway to improve mental health services, little progress has been seen over a decade’s focus on mental health problems. Many ‘blueprint’ documents to guide mental health reform have been produced, but there remain substantial gaps between aspirations and reality. While the report makes mention of some noteworthy projects, there is simply no evidence of a systematic commitment to improved quality care across the board. Aside from providing simply inadequate resources to match unmet needs, governments are guilty of a lack of political leadership, with states and the Commonwealth playing the ‘blame game’ over the mental health crisis and encouraging a culture of denial that a serious problem exists. No state was beyond reproach in the report. Even Victoria, one of the top-performing states, was berated for directing insufficient attention to responding constructively to consumers’ and carers’ experiences. 

This report does not provide a comprehensive overview of human rights violations in Australia’s mental health system. Such a report was prepared over 12 years ago and has yet to be properly implemented by government, despite basic system failures being brought to their attention every five years since 1993.  Not for Service emphasises the unchanging nature of Australia’s mental health system as perceived by consumers, carers and practitioners and the failure of government to address issues of fundamental importance. What this report successfully accomplishes is to put a human face to the ongoing crisis, incorporating the frustrations and emotions of individuals from a variety of backgrounds and experiences of the system. Arguably more powerful than pure statistics, the report is a compelling insight into the true nature of Australia’s mental health system.  

Calling for an enormous $5 billion Australian dollar increase in funding over five years, as well as accountability mechanisms and action to address the declining morale and skills shortages evident in the mental health care workforce, the report has yet to elicit a formal response from government. Prime Minister John Howard has, however, set up a government team to analyse the findings. Past experience and the emergence already of divisions within and between state and federal governments as to where responsibility for mental health should fall do not herald a promising start. Perhaps, however, various governments will act as they failed to do 12 years ago and address the debacle that is Australia’s mental health system.

 Human Rights Features