Royal Commission Into Victoria’s Mental Health System
"The promised state funding for mental health services is essential and it is welcome. It will make a difference to people’s lives right across the state. But let us not stop there.
Dr READ: During my medical career I heard from many patients and also from friends struggling with depression or, less commonly, the voices in their heads. Mental illness is often a frightening and isolating experience, and it was no doubt made more difficult for my patients when I often failed to provide or find the best support for them. Since the mid-1990s it has been difficult to find help from the public mental health system. The phone numbers have been hard to find, and when you call you can wait a long time to get someone willing to accept a referral. If it is frustrating for health workers, imagine how it must feel for the person they are trying to help. The state mental health system was unique in my experience in being unable to reply to letters from doctors. This may seem trivial, but it is an essential part of communicating and coordinating a person’s medical care. Poor communication is a symptom of a system under stress.
None of this should reflect on the quality or effort of the staff. They simply are not given the time or the resources that they need to do their job. Over the past 25 years public mental health services have contracted in Victoria, as funding has not kept pace with demand. This is a defensive shrinking, where hospital mental health services and community clinics have had to stop taking on categories of patients that they previously would have seen. The gap between what one service provides and another will accept widens, and the mentally ill fall into it.
The Royal Commission into Victoria’s Mental Health System report describes a system driven by crisis and one where people whose conditions may be too serious for GPs fail to raise enough red flags to be seen as serious enough for the beleaguered public system. And if they cannot afford the out-of-pocket cost of seeing a private psychiatrist, they are stuck in what the royal commission calls the ‘missing middle’.
By 2018 Victoria was spending less per capita on mental health than any other state—it was being starved of funding—so this government declared the system to be broken and called a royal commission. I am sure the government did not intend to diminish the work of the staff in the system by saying the system was broken and required a royal commission to diagnose the problem. Equally I doubt anyone was surprised at the royal commission’s diagnosis of starvation. I wondered why we needed a royal commission back in 2018 when it was announced when what was really needed was funding. But on Tuesday I think Professor Patrick McGorry at least provided part of the answer by saying that the royal commission created the ‘authorising environment’ for the new mental health system recommended by the royal commission.
The recommendations of the royal commission will require a substantial and sustained increase in investment if they are to be implemented fully, and the government says they will be. The Greens welcome this commitment not just of caring but also of spending serious money on mental health, because that is what our economy is for, after all—for looking after all people. There is no question that the royal commission has carried out the most complete and exhaustive review, and while it is too big to digest in a few days, I am heartened by what I have seen so far.
There are a few recommendations that I would like to highlight. First is the use of workforces with personal experience of mental illness. I am pleased that people navigating the mental health system will be able to do it with the support of workers who know just how frightening it can feel, indeed how unsafe it can actually be. People admitted to psychiatric wards are at risk of psychological trauma from the experience and they are at risk of sexual assault. Involving people with personal experience of mental illness in the training and the delivery of care should help to make services safer for patients as well as for staff, as will the royal commission’s recommendations aimed at improving trauma-informed care and improving sexual safety. I have always been nervous about that, particularly when referring women patients for admission. Recommendations to minimise the use of compulsory treatment and end the use of restraint and seclusion should also reassure us that the system will become safer.
The second area I would like to highlight is the commitment to funding for mental health services for First Nations people run by First Nations people. This is important because with mental health, as with broader health issues, the gap between First Nations people and the rest of us is, to put it bleakly, wide. First Nations people are more than twice as likely as other Australians to be hospitalised for self-harm or to suicide. This cannot be the life prospects that we hand to young First Nations people.
The third thing I would like to highlight is the commitment to youth mental health. Most mental health conditions surface when people are young, and mental health is a big issue in many young people’s lives—either that or in their friends. The royal commission should make it easier for young people to obtain mental health care and help that is tailored to them. But keeping people healthy is about much more than just the medical system. Mental illness makes it harder to keep paying the rent and increases the chances of people being made homeless. More than a third of adults and teenagers seeking help from specialist homelessness services in 2017–18 reported a diagnosed mental illness. Homelessness exacerbates mental health conditions as well as dramatically increasing the chances of being arrested.
We do not just need mental health services to deal with this, we need more housing, and by that I do not just mean community housing. Community housing is a great thing, but it largely helps people who are on low incomes but who can keep paying the rent and be a reliable tenant. That covers some people with mental illness. For those who cannot, we need a safety net like public housing, not the streets. The royal commission recommends 500 medium-term places for young people and 2000 units planned for people living with mental illness—a good start, but that will barely touch the sides of the 100 000 people on the public housing waiting list. Victoria’s Labor government is building more community housing, but the commitment to public housing is yet to be demonstrated.
A significant part of our mental health system is not where you would expect to find it. It sits within our prison system. Australian Institute of Health and Welfare data shows that 40 per cent of prisoners have had a mental health diagnosis, and that is probably an underestimate. Prisoners are more than 10 times as likely to be diagnosed with psychosis than are the rest of the population, according to a New South Wales study.
So if we are serious about reforming our mental health system, we must reform at least parts of our criminal justice system. We are imprisoning people at around double the rate that we did 20 years ago, which equates to many thousands more people with mental illness being imprisoned every year in Victoria. Our current justice system is in many ways more insidious and backward than a half a century ago when Victoria’s Lunacy Act 1890 was the least enlightened enough to take vulnerable people out of workhouses and prison cells and put them into specialised therapeutic environments for treatment. But the reality is that in the last 20 years we have been rapidly reinstitutionalising people with mental illness, not in asylums but in our prison system. Sometimes prisoners are not imprisoned for committing a criminal offence, as the Ombudsman recently reported, but are held in prison and often in solitary confinement simply because we have no adequate non-custodial facilities for people with complex behaviours.
Why are we using our prison system as accommodation for people with complex needs? It is because Victoria’s populist politicians have over time sought support by solving imaginary law and order problems rather than addressing the very real problems of people with complex mental illness and behavioural issues in our society. We have a system where mentally ill people who commit minor offences are remanded in prison because of the way our new bail laws treat repeated nuisance offences. You do not get specialised care on remand, you do not get rehabilitation on remand and there is a good chance you may be assaulted. On release after a few weeks you will need to reapply for support payments and start over again with any medical or addiction treatment, and you may struggle—you will struggle—to find housing. Still we wonder why people with mental illness are over-represented as repeat minor offenders. The government has created a system where for many people with mental illness the first time they get a bed will be when police remand them in custody, and from this point many of these people will have ongoing engagement with our prison and criminal justice systems.
The good news is that the royal commission recommends that the use of police be minimised in responding to psychiatric emergencies and that the assessment and referral court services be expanded to meet demand. The report recommends at least 100 new beds for the Thomas Embling forensic psychiatry hospital. All this and other forensic psychiatry reforms and additional services inside and outside prison will be a great help, but if we are serious, we also need to reform those bail laws. The royal commission may have created the authorising environment for the reforms, but it does not guarantee a well-funded and compassionate system for the long term. Nothing can do that.
Our health system has a fundamental gap which widens whenever there is any contraction in funding. This is the gap that sits between the federally subsidised private care known as Medicare and the state-run public system, which is mostly our public hospitals. For 30 years Victorian governments have been urging their public hospitals and clinics to shift an ever-growing proportion of their expenses onto Medicare. Federal governments have often failed to increase Medicare rebates to match the expectations of doctors, and patients have paid the increasing difference. Psychiatrists often leave the Victorian mental health system because it is so poorly resourced and, unlike nurses, they have the option of working in private practice. As public funding shrinks from both state and federal governments, the rising out-of-pocket costs deter patients from seeking care, so the gap between the Medicare-funded private sector and the state public sector will remain. I hope it closes as the public mental health system starts to grow again, but it will also be affected by the level of federal funding to Medicare. It is not yet clear to me how much of the promised growth in Victoria’s mental health system is reliant on Medicare-funded private services, but this may also be important in determining the success or otherwise of the new system. One day a federal government should examine how to permanently close that gap.
Nevertheless, the promised state funding for mental health services is essential and it is welcome. It will make a difference to people’s lives right across the state. But let us not stop there. Let us also build the public housing we need and treat mental illness as more a health issue than a law and order one so people struggling with mental illness do not find themselves facing homelessness or jail and so our society becomes fairer for all of us.
