The next NSW Government must make health services much more accountable for their use of mental health funding, and deliver major new investment in community mental health services, according to psychiatrist Alan Rosen, Professorial Fellow, School of Public Health, Faculty of Health & Behavioural Sciences, University of Wollongong.

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Alan Rosen writes:

It’s a familiar story: Imagine that you are an ageing lone parent trying to provide home care for a strong 29-year-old son, struggling with a smouldering longterm psychosis in an outer local health district (LHD) of a metropolis in NSW.

You are lucky if your family gets a home visit from the local community mental health team more than twice a year, because it has been run down to half its staffing.

Even so, you may only get this input if the person is on a Community Treatment Order, because the team staffing is now so sparse that it can only provide any regular care management for those on involuntary orders.

Consequently this young man goes off his medication and starts pushing his parent around, physically endangering his main carer and precipitating yet another involuntary admission to hospital. This involves an epic cast of police, ambulance, mental health clinicians, causing a stigmatizing spectacle in the immediate neighbourhood.

If resources had been adequately applied, and not depleted by his local health district to pay for overruns in medical and surgical procedures, and the imposed costs of otherwise worthy Emergency Department targets, this young man and his family should have had the regular services of an Assertive Community Treatment team, which could home visit on a daily basis if required, to keep him engaged in treatment, and to relieve his ageing family of carrying the burden of his home care virtually alone [See: Stop the Rot] .

There is no protection at LHD level of the Mental Health budget or the cash subsidy that supports the budget…this is current policy. This has occurred to some extent under successive governments, but under this administration it has been far more blatant and severe, and the losses to mental health from LHD siphoning have gone from $20 million annually in 2009 (NSW Auditor-General’s report in 2010) to well-informed insider estimates of more than eight times that now.

The biggest impost seems to fall on interdisciplinary community Mental Health positions as they are easier and less visible targets than the staffing of the bricks and mortar of inpatient facilities.  So, the painstaking engagement of early intervention and mobile crisis teams cannot be delivered, and emergency departments and inpatient units get overloaded with urgent psychiatric referrals.

If resources were adequately applied, and not depleted by local health districts to pay for overruns in medical and surgical procedures, [as reported in the SMH on 10 & 11 March 2015 by Amy Corderoy], they and their families would not be left alone in the community, with no-one to help them but increasingly only the police [See: Mental health cases spike as police seek new role].

Further, the dramatic recent reductions of public child psychiatrist positions (Western Sydney) and all public psychiatrist positions in rural Western NSW and elsewhere, are a false economy, especially as there is no undertaking that these savings will be redeployed in mental health at all.

There are now few controls on LHD siphoning from mental health budgets, and there is no independent and regular forensic level auditing of LHD MH budget, cash or service delivery, so there is little real accountability…reporting on mental health is done with a very broad brush. It could be called the French Impressionistic School of organizational accountability.

As to the growth of the NSW mental health budget to $1.62 billion:  Minister Jai Rowell and departmental responses refer to this as the annual “spend” on NSW public mental health services.

But in reality, this is only the nominal budget, not the actual expenditure on mental health services. These allocations appear to be illusory, like an old Wild West movie town frontage. They are only just a theoretical starting point.  They do not represent what is actually spent on mental health, nor the acquittal:  the reconciling of the announced and published budget for mental health services with what is actually spent on mental health.

The LHDs are allowed by the Ministry of Health to shift resources allocated to mental health for other purposes, thereby continually eroding and dismantling mental health services bit by bit. Note that not all LHD’s do this, but many do.

The pre-election enhancement for mental health services announced by the Premier in December is most welcome, but is likely to suffer the same fate of diversion out of mental health.  In any case, at only $38 million a year over 3 years, this is only a small gesture compared to the estimated more than 4 times that amount that is taken out of mental health budgets by the LHDs every year.

This does not include the savings from mental health intended by the current merging of nearly all dedicated mental health support services (eg workforce training, mental health service information unit responsible for comparative monitoring of quality of services) into generic health services, where again they will inevitably end up at the bottom of the pecking order, losing funding for mental health priorities.

These figures are admittedly only well-informed estimates, necessary because, so far under this government, there have been no systemic audits done of actual expenditures on mental health, nor are these details on the public record. These estimates depend on accounts from very senior and committed public sector senior mental health personnel who cannot speak up because of continuing instances of severe recriminations.

What will be the consequences if this is allowed to continue?

The NSW Government has endorsed the Strategic Plan of the MH Commission of NSW, which proposes shifting the balance of Mental Health Services towards the community, in accordance with both the evidence and the wishes of service users and their families.

But as we have learnt from successful shifts elsewhere to community re-provision, major new investment in community mental health services must precede any decrease in hospital placements, to move people with mental illnesses from institutional to stable supported community living.

However, successive NSW governments, more than any other Australian jurisdiction, have continued to squeeze and deplete community mental health services.

History has also demonstrated that such serial disinvestment will inevitably, if not effectively restrained, lead to further gaps in and dismantling of mental health services, worsening outcomes for people with severe mental illness, and at some point, a formal calling to account by public inquiry, as both avoidable deaths and other critical incidents accumulate.

What steps can Government take to start correcting this looming crisis? 

We need a process for annual independent full-scale forensic audits of Mental Health budget, cash and service delivery needs, service gaps and quality improvement to be instituted with annual reports to Parliament.

This is the only way to get to the truth, and ensure some stability of mental health resources. The best way is to strengthen the Mental Health Commission of NSW by providing it with statutory or delegated powers of audit over mental health budgets, expenditure, acquittal, and quality of  LHD and statewide mental health services, reporting these comparatively on an annual basis.

Government must instruct the Ministry of Health and the LHDs to restore to mental health services the mental health resources taken from mental health budgets over the last four years.

The budgets of statewide mental health services and mental health dedicated support services should be restored to a circumscribed mental health entity like the specific children’s health LHD equivalent or an affiliated health organization dedicated to mental health.

We need to follow the evidence, to make a real difference: to disseminate throughout the state ( with proxies in rural/remote areas) the evidence-based community mental health interventions and teams which will achieve the most practical and quality-of-life improvements in personal  outcomes.

We need to walk together with government, on a bi or tri-partisan basis wherever possible, by providing Government with reliable and robust arm’s length advice about whether the reforms are adequately resourced and on track or not, and by sustaining good communication between them, service users and providers. The Mental Health Commission of NSW should be strengthened to enable this.

In this pre-election context, we need a firm commitment from the Premier (as good mental health services are truly an all-of-government endeavour) and all sides that:

• the leaking of budgets will stop

• the Mental Health Commission of NSW will be empowered to report annually on arm’s length audits of all mental health resources, local and statewide

• adequate enhancements will be made to shift the balance of mental health services more towards the community, implementing the strongly evidence based modules of community mental health care widely, while also funding inpatient units properly as essential elements (though no longer the centre of gravity) of the spectrum of services.

Professor Alan Rosen, Professorial Fellow, School of Public Health, University of Wollongong; Clinical Associate Professor, Brain & Mind Research Institute, University of Sydney; Secretary, NSW Comprehensive Area Service Psychiatrists Network.; Former Deputy Commissioner of the Mental Health Commission of NSW, March 2013-March 2015.

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