National mental health policy
The relationship between mental health services and the general health sector
Linking mental health services with other sectors
Promotion and prevention
Primary care services
Carers and non-government organisations
Mental health workforce
Research and evaluation
Monitoring and accountability
Consumer rightsThe rights and civil liberties of people with mental health problems and mental disorders must be guaranteed and protected. Mental health services should be delivered in the least restrictive environment, with an emphasis on privacy, dignity and respect. Consumers must have access to information on their rights and to advocacy services to ensure their rights and to mechanisms for complaint and appeal.
In response to these needs, the United Nations has ratified a Resolution on the protection of rights of people with a mental illness, and the Australian Health Ministers have adopted a Mental health statement of rights and responsibilities (March 1991). This policy endorses the rights outlined in these documents. They include:
- timely and high quality mental health care in a manner which is conducive to continued consumer participation in community life;
- respect for individual human worth, dignity and privacy;
- access to services and opportunities available to others;
- information, education and training about mental health problems and mental disorders, and the treatment and services available to meet their needs;
- participation in decisions regarding treatment, care and rehabilitation;
- access to mechanisms for complaint and redress;
- right to refuse treatment, unless subject to mental health legislation;
- access to advocacy support where necessary to ensure participation in treatment decisions; and
- opportunity to live, work and participate in the community to the full extent of their capabilities without discrimination.
- To have the rights contained in the Australian Health Ministers' Mental health statement of rights and responsibilities and in the United Nations Resolution on the Protection of rights of people with a mental illness affirmed in mental health legislation.
- To ensure that the Commonwealth Government and all State and Territories Governments have mechanisms for protecting those rights.
The relationship between mental health services and the general health sectorHistorically, mental health services tended to be separated physically and organisationally from the mainstream health system. The approach of providing comprehensive mental health services within the community has demanded the forging of new relationships between mental health services and the wider health sector.
Two complementary policy aims form the basis of the organisational relationships which should exist between mental health and general health services.
Mental health services should be part of the mainstream health system. In some cases, such as acute inpatient psychiatric care, this entails delivering services within a general hospital setting. In other cases a specific mental health service will operate from a separate location, but be managed within the wider health system. This policy requires that mental health services be an integral part of whatever organisational structure exists for general health services in a State/Territory.
The aims of linking mental health services into the wider health system are to:
- reduce stigma attached to people with mental health problems and mental disorders;
- improve the quality of mental health services;
- encourage people to seek help early;
- enhance equity of access to other health services; and
- achieve more decentralised mental health services closer to people's family, community and cultural networks.
These policy aims need to be reflected in financing relationships and responsibilities. Mental health services form part of basic health care which should be universally accessible. As such, the financial arrangements for mental health should be incorporated into general health financing arrangements. Currently, in many instances they remain separate. Alongside this mainstream approach to mental health financing, mental health service resources should be identifiable and should be allocated through a mental health program whether the services are within general health or separate mental health settings.
The pursuit of both the mainstream and integration policy principles may occur in different ways, depending on State/Territory and regional/area circumstances. A single professional or team may be responsible for a person's care whether the person is being treated in a general hospital or in a community mental health service ('continuity of care provider'). Case management systems may be introduced where a professional within the mental health service is responsible for the overall co-ordination of a person's care across various agencies. Such case management systems are particularly valuable for the management of people with severe mental disorders, and can operate using various financing mechanisms such as the 'budget holder' approach which gives a program manager responsibility for purchasing services needed by the person.
- To expand the proportion of acute psychiatric inpatient care provided in general hospitals rather than separate psychiatric hospitals so that most acute psychiatric care is delivered in general hospitals, and to ensure psychiatric units in general hospitals are appropriately designed for the patient population.
- To maintain or establish an identifiable and integrated mental health program at the State/Territory and area/regional levels. This program would be responsible for the overall planning of all specialised mental health services and would advise on the allocation of resources between components of mental health services.
- To include the integrated mental health service within the mainstream organisational arrangements for general health services, such as area/regional management systems.
- To introduce systems, such as case management, which improve continuity of care and comprehensive services for people with mental disorders who receive services on an ongoing basis from numerous agencies and locations.
Linking mental health services with other sectorsSpecialised mental health services can meet only some of the varied needs of people with severe mental health problems and mental disorders. Access to housing, accommodation support, social support, community and domiciliary care, income security and employment and training opportunities may have a significant impact on the capacity of a person with a severe mental health problem or mental disorder to manage in the community.
The separatist model of mental health care has often led to discrimination whereby the various needs of those with severe mental health problems and mental disorders are seen as the total responsibility of mental health services. In some instances, those who have used mental health services have been excluded from eligibility for mainstream services. Often, the discrimination is more subtle, with them being given low priority in the allocation of resources or their specific needs not being recognised.
The national policy aims to encourage co-operation between mental health services and the various programs and services needed to enable people with severe mental health problems and mental disorders to participate more fully in community life.
- To eliminate any explicit or implicit discrimination against those with severe mental health problems and mental disorders in programs and services within and outside the health sector.
- To develop formalised policy and planning arrangements at Commonwealth, State, Territory and area/regional levels to ensure that all programs relevant to those with severe mental health problems and mental disorders adequately address their needs.
- To encourage interagency links and service delivery arrangements at the local and area/regional level to ensure that access to services for people with severe mental health problems and mental disorders reflects their relative need for those services.
Service mixA comprehensive mental health service system has some important characteristics. It needs to be adequately resourced and accessible to respond to the range and variety of needs of persons with severe mental health problems and mental disorders. An integrated and comprehensive mental health service must cater for both acute episodes and long-term needs. Services for those experiencing acute episodes would include acute hospital care, community and home-based acute care, emergency assessment and day treatment. People with severe mental disorders require outpatient treatment, social and vocational rehabilitation, varying degrees of residential support and long-term care.
A comprehensive mental health service system must provide for continuity of care so that consumers can move between services as their needs change, thus ensuring that they receive the most appropriate service at any time. A system offering continuity of care can reduce hospital readmissions through follow-up support from community and home-based services following discharge from hospital.
Adequate resources must be made available to meet the needs of special 'at risk' groups, such as older people, children and adolescents, people from non-English speaking backgrounds, Aboriginal and Torres Strait Islanders, people living in remote and rural areas, and offenders with a mental disorder. Since the needs of special groups are likely to vary between communities and over time, it should be the responsibility of those planning and allocating resources within an area/region to assess priorities for resource allocation.
The optimum mix of services should be determined by each mental health service system, based on the needs of the population it serves and not bound by historical patterns of service delivery and resource allocation. This population focus should determine the allocation of resources. Consumer and community consultation and participation in decision-making about service mix is essential.
The mix of services for a particular population should be based on need and should be guided by the aims, principles and policies of the National mental health policy. It has been accepted that there is currently an imbalance in the mix of services, derived from the traditional patterns of service delivery and the difficulties in moving quickly to translate the new approach to mental health service delivery into practice.
Currently, too much resource emphasis is given to separate psychiatric hospitals. In some cases, it is both possible and desirable to close them and replace them with a mix of general hospital, residential, community treatment and community support services. Replacement services should include specialised mental health services and access to mainstream programs such as disability support, supported accommodation and domiciliary care. With such an approach it can be expected that the use of psychiatric hospitals will diminish.
Although it is accepted that, in general, prolonged psychiatric hospitalisation is undesirable, there is a small number of people who require such care. They include: people with mental disorders who are seriously behaviourally disturbed and a danger to themselves or others (including offenders with a mental disorder); and people with mental disorders who are unable to live in the community despite available community support.
Some of these people may be best placed in a protected environment because of the risk they pose to themselves and/or others. To address their rights, the facilities for these people need to be maintained at an acceptable standard appropriate to their needs. The reduction in size or closure of a psychiatric hospital may involve the development of new facilities, or the upgrading of existing facilities, to accommodate these people.
Psychiatric hospital services are often centralised within a limited number of institutions in a State or inappropriately placed in small country towns. This contributes to the stigma associated with mental health services and has led to a maldistribution of mental health resources.
There is generally a paucity of appropriate accommodation support services for people with severe mental health problems and mental disorders who are unable to live in their own homes. These services are essential for many people in making the transition from institutional to community care while maintaining a reasonable quality of life without undue reliance on psychiatric hospitals. Some accommodation support services should operate as part of a specialist mental health service, while many others should be provided through general accommodation support programs.
Community based services are relatively underdeveloped and their distribution is somewhat uneven between localities/areas. These services are essential for those requiring ongoing care and are particularly important when institutions are being reduced in number. This reduction limits the 'revolving door' phenomenon in which people without adequate community treatment and support have frequent and regular acute admissions to hospital. It has now been accepted that community-based services need to be provided reasonably close to where consumers live.
- To ensure each State, Territory and area/region has a plan for the mix of services available to its population and that this plan is developed through a consultative process and takes account of the needs of special groups.
- To reduce the size or to close existing psychiatric hospitals, and at the same time provide sufficient alternative acute hospital, accommodation, and community based services.
- To upgrade the remaining psychiatric facilities which are needed to provide treatment or care on a medium or long-term basis for those whose appropriate placement is in separate specialist psychiatric hospital facilities.
- To decentralise the provision of psychiatric hospital services to ensure adequate access across all areas/regions to general hospital inpatient services and community based services including crisis, assessment and treatment, rehabilitation/support, and domiciliary and outreach services.
- To increase the number and range of community based supported accommodation services and ensure a range that provides a level of support appropriate to the needs of the consumer.
- To identify areas where the separation of Commonwealth and State funding for mental health treatment services compromises the targeting, integration, and distribution of mental health services and to introduce measures to overcome this.
Promotion and preventionSociety's attitude to mental health affects the impact of a mental health problem or a mental disorder on an individual. The public is largely uneducated about mental disorders. This situation needs to be redressed by disseminating information on the types and effects of mental disorders, prevalence in the community, treatment methods and prevention. As a result, those with mental disorders will be given more public and political attention, be better understood, less feared, less discriminated against and have better access to general community life.
The efficacy of primary prevention measures has not been demonstrated for most severe mental health problems and mental disorders. Although the causes of mental disorders are yet unclear, there is evidence that heredity is a significant factor, and that mental health is often compromised in times of stress such as bereavement, relationship breakdown, unemployment, social isolation and at times of accidents or perceived life-threatening illness. The incidence of these conditions is also higher in adolescence and old age. Indigenous and immigrant populations and socially disadvantaged families are also recognised as being 'at risk'.
The evidence in support of the effectiveness of secondary (early intervention) and tertiary (rehabilitation) prevention is stronger, and the provision of such measures is regarded as central to mental health care. Early diagnosis and intervention are particularly effective, as are programs which assist people to deal with life events which may place their mental health at risk.
- To develop programs which educate the public on mental disorders, including those initiated through mainstream health promotion activities.
- To develop and evaluate primary, secondary and tertiary preventive programs as an essential component of all care provided for people at risk of mental disorder.
- To encourage further research into the causes of mental disorders and the development and evaluation of primary prevention interventions in response to emerging scientific knowledge.
Primary care servicesGeneral practitioners are often the initial point of contact for people with mental health problems and mental disorders. It has been estimated that they represent about a quarter of people visiting general practitioners.
Primary health care services also have an important role in caring for people with mental disorders and for referring those with serious disorders on to specialised mental health services.
Considerable attention needs to be given to increasing the skills, at both undergraduate and graduate level, of primary health care providers to strengthen their capacity for assessment, diagnosis, treatment and referral of people with mental health problems and mental disorders.
Workers in other sectors, such as police and teachers, can assist in the identification and referral of people with mental health problems and mental disorders and can participate in their management. These workers need to be adequately informed and resourced to enable them to perform this role appropriately.
The effectiveness of primary care workers in dealing with people with mental health problems and mental disorders is improved when they have access to specialist mental health professionals. This is a particularly important issue in rural and remote areas where the scarcity of specialised mental health services has meant that primary care workers have had a greater role in the treatment and care of people with mental health problems and mental disorders.
- To ensure that educational programs for primary health care professionals and others with a primary care role contain, within their curriculum and continuing education programs, adequate coverage of mental health issues.
- To provide support to primary carers by ensuring that they have access to specialist mental health resources, particularly in rural and remote areas.
Carers and non-government organisationsMany people with mental disorders are cared for in the community by 'unpaid' carers. Non-government organisations have performed a key role in providing support services for those with severe mental health problems and mental disorders, in advocating for services to be more responsive and in educating and supporting carers. The funding of non-government mental health organisations has been relatively limited.
Support services, which have been recognised as important for sustaining the carers of people with mental disorders, are not well developed. Support services may be provided through specialist mental health services or through other appropriate community programs.
- To support the development and expansion of non-government organisations to assist carers and promote self-help and consumer advocacy, through information provision, opportunities to participate in mental health service decision-making and funding.
- To expand community-based support for carers.
Mental health workforceThe effectiveness of mental health services is dependent on an adequate supply of highly trained professionals. There is evidence of a maldistribution of psychiatrists between States, urban and rural areas, public and private practice, and within clinical sub-specialities in psychiatry. Allied health staff (including social workers, clinical psychologists and occupational therapists) are a key component of specialised mental health services.
Similar problems of maldistribution often exist for allied health staff and, as a result, governments need to ensure that there is an adequate supply and proper distribution of the allied health workforce.
The training of specialist nursing staff to work in the mental health area is of crucial concern. It is extremely important that Governments and tertiary training institutions ensure that nurse education includes adequate basic and post basic training in psycho-social and biomedical aspects of health care.
- To achieve a better distribution of psychiatrists between States/Territories, geographic areas within States, public and private practices and within sub-specialities.
- To ensure that the number of graduates, and their level of skills, from tertiary based programs of nurse education meet the service requirements of specialised mental health services.
- To ensure an adequate supply and a more equitable distribution of allied health staff.
- To encourage continuing education for all mental health professionals.
LegislationLegislation is essential for defining and protecting the rights of those with mental disorders and for balancing these rights with the community's legitimate expectation that it be protected from harm.
However, mental health legislation varies between States and Territories. While some have reformed their legislation, others are in the process of amending it. Consistency in mental health legislation is an important part of the reform process to ensure that people with mental disorders have similar rights and expectations about the way they will be treated. This is particularly important for the treatment of involuntary patients.
Australia's obligations arising from the endorsement of the United Nations Resolution on the protection of rights of people with a mental illness highlight the need for consistent mental health legislation across Australia.
Other legislation which affects those with severe mental health problems and mental disorders needs to be consistent with the principles set out in the National mental health policy.
- To ensure that mental health legislation across Australia is consistent and that it affirms the rights contained within the Australian Health Ministers' Statement of rights and responsibilities and the United Nations Resolution on the protection of rights of people with a mental illness.
- To ensure that legislation in other sectors is consistent with the principles set out in the National mental health policy.
Research and evaluationProgress in achieving better consumer outcomes in mental health depends on the availability of adequate research into causes of mental disorders and evaluation of the effectiveness of various service interventions. In mental health, these research and evaluation issues are particularly complex, as they are grounded in knowledge from many fields including the biomedical, psychological, and social sciences.
Mental health research has traditionally been given a low priority in gaining access to research resources.
As there has been no consistent collection of mental health data across the States and Territories, the application of a national policy approach has been limited, constraining mental health planning and making utilisation review and quality assurance of programs difficult.
- To promote increased basic and applied mental health research and its application in prevention and intervention programs.
- To institute regular reviews of outcomes of services provided to persons with serious mental health problems and mental disorders as a central component of mental health service delivery.
- To develop a national mental health data strategy.
StandardsMental health services should be of the same high quality that Australians have come to expect of their general hospitals and other health services. However, the historical approach to mental health care has not always been conducive to achieving high standards.
The separation of mental health services from mainstream health services has contributed to the stigma associated with people with severe mental health problems and mental disorders and to the lower status accorded to psychiatry and its related professions compared with other areas of health practice. The absence of accepted consumer rights and society's attitude towards those with mental disorders have also reduced the potential to achieve high standards of care.
The new approach to mental health care which has continually developed over the last 30 years is changing this. The policy direction set by the Australian Health Ministers in the National mental health policy is intended to further reinforce these new conditions for creating high standard care.
Professional bodies should have a central role in developing protocol for clinical treatment and this should be encouraged. It is widely recognised that quality assurance programs within health services are an important part of achieving high standards and this applies equally to mental health services. The extent to which individual mental health services have introduced measures to assure high standards of care varies.
Although higher standards can be expected with these changes, it is important that specific and quantifiable measures be developed to assess the impact of services on consumer outcomes. Substantial development work is needed to create such measures.
- To encourage the development of national outcome standards for mental health services, and systems for assessing whether services are meeting these standards.
- To ensure all mental health services have quality assurance programs.
- To support appropriate professional bodies in developing protocol for clinical treatment.
- To encourage each mental health facility to be fully accredited by an independent and recognised accreditation body.
- To ensure that all services satisfy the standards and rights contained in the United Nations Resolution on the Protection of rights of people with a mental illness and the Australian Health Ministers' Mental health statement of rights and responsibilities.
Monitoring and accountabilityThere needs to be greater accountability and visibility in reporting progress in implementing the new national approach to mental health services. Currently mental health data collection is inconsistent and would not be adequate to enable an assessment to be made of the relative stage of development of the Commonwealth and each State/Territory Government in achieving the objectives outlined in the National mental health policy.
It is essential that such a consistent system of monitoring and accountability be created. In developing such a system, it needs to be recognised that each State and Territory will be at a different stage as a result of the historical development of its mental health system. The central approach should be to measure progress in each State and Territory.
- To develop nationally agreed measures of performance in relation to each of the objectives in this policy and others which the Commonwealth, States and Territories regard as indications of performance in relation to this policy.
- To report annually and publicly, in a timely fashion, on the progress of the Commonwealth and each State and Territory in relation to these performance indicators and to compare them to their previous performance.