Mental health in Victoria struggles with a major paradox. On the one hand there has never been greater acceptance of mental illness. On the other, the failure of this to translate into better services for people with mental illness and their families is stark. It is a massive disconnect and things are getting worse.
Mental illness is the awakening giant of health care, yet its voice keeps getting lost in public policy. The voice of people with more serious forms of mental illness is almost inaudible and those who care for them, especially clinicians, are often actively prevented from speaking on their behalf. As a clinician who hears stories of neglect from the voiceless daily from all parts of Victoria, I want these stories to translate into action.
Illustration: Matt Davidson.
We know from national surveys that the public consistently rate mental health as one of the top priorities they want governments to tackle. The work of beyondblue, SANE, Mental Health Australia and others has ensured that mental illness is now out of the shadows. Everyone knows that mental ill health will affect us all one day.
The ABC will kick off an unprecedented national conversation on mental health in October through its “Mental As …” campaign and the AFL is seriously exploring the mental health space. This burgeoning awareness means that people with mental ill health are quite rightly demanding the same levels of access and expertise that are routinely available in the rest of health care. How are we going with this?
Patrick McGorry: Victoria is overdue for a radical review of scope, governance and investment in mental health.
Successive federal governments of both political persuasions from Hawke to Abbott have certainly played their role with strategic and innovative investments in mental health care. What of the state government contribution?
Starting in the late 1980s and exploding through the ground-breaking reforms of the Kennett era and beyond into the early 2000s, Victoria established a glowing reputation as the international epicentre for innovation and evidence-based reform in mental health. The creation of assertive community mental health teams, mainstreaming of acute care, the early psychosis and youth mental health reforms, the clinician-scientist model of leadership and consumer participation in mental health were central features. Victoria was enviously regarded and later emulated by other states and many jurisdictions overseas. Not any more.
Over the past decade we have become complacent. The new system started to buckle under the demand pressures arising from an educated community seeking help in a timely fashion and from steady population growth. Successive governments have failed to plan and invest for this.
The new community mental health system of the 1990s was created by cashing in the beds of the old asylums but it has not been maintained or kept pace with community need. In fact, in the absence of a reform in financing models it is shrinking rapidly, and seems unsustainable in a world in which states “run hospitals”. Community mental health services, through which most of the care of the mentally ill needs to occur, operate under the governance of acute hospitals which essentially are about beds. Hence, whenever financial shortfalls occur the community mental health budget is a very soft target. Every year these services are eroded. This is a death of a thousand cuts.
These cuts mean that a growing number of people with serious mental illness are being denied stable case management in the community, only to turn up later in desperate and life-threatening situations at the emergency department. The revolving door is revolving even faster. Meanwhile, other symptoms of decline include a stalled commitment to academic leadership in clinical services, the key source of innovation, and a decline in the morale and culture of inpatient units and community teams. While the non-specialist or NGO community mental health sector is now a much valued component of a modern system of care, its future is in doubt in the wake of the recent recommissioning and the advent of NDIA, which many fear will result in the withdrawal of even more services to the seriously mentally ill.
The role of, and respect for, expert clinicians in public mental health has been steadily reduced. The public have a genuine need for this precious expertise just as they do in cancer or cardiac disease. Non-clinical support is essential but no replacement. I’m sad to say specialist expertise is no longer properly respected, its voice becoming as marginalized as that of the patients and families.
Two decades after deinstitutionalisation, state-funded public mental heath systems around Australia are in deep trouble. It is particularly painful to watch this happen in Victoria, the state that was at the vanguard of progress under both Coalition and Labor governments.
Though mental health is a key state government responsibility, we are yet to hear from the major parties about their plans for the next period of government. Have they jointly decided that mental health is not an election issue?
I am not interested in criticising past failures but do expect a genuine commitment to reform and investment from both the Coalition and Labor. What can be done? Definitely not another set of Band-aids and more of the same. Two decades after the landmark Kennett reforms that closed our institutions, and mainstreamed mental health care, we are overdue for a radical review of scope, governance and investment in mental health, which also should be progressively expanded over time to achieve parity with physical health.
This must be a project for the first 100 days of the next State government. Victoria has the leadership, the talent, the foundations, the financial resources and the civil society to resume national leadership in mental health care, and finally end the lethal discrimination that still exists in our health care system.
Patrick McGorry is professor and executive director of Melbourne University’s Orygen Youth Health Research Centre