This week in Western Australia is Mental Health Week, with more than 50 events and activities promoting the Mental Health Commission’s Act-Belong-Commit message.
A system in crisis?
Most stories about mental health crises in WA follow a similar format. A medical professional or family carer contacts the media, saying the system is under pressure and about to blow.
The government responds by saying it has done plenty to add capacity and it is only the occasional spike that throws things into chaos. Essentially, it says, ‘nothing to see here’.
Meanwhile, Australia’s suicide toll more than doubles its road toll.
In July 2014, the Royal Australian College of Psychiatrists WA warned a parliamentary inquiry the system did not have enough psychiatrists or beds to cope with demand.
The following events seemed to make this terribly clear.
‘Code Yellow’: a year of emergencies
One year ago, in October 2014, WA opposition mental health spokesman Stephen Dawson revealed WA’s mental health authorities had declared an emergency after running out of beds. For only the fourth time ever, an emergency ‘code yellow’ in Perth was called. At its peak, 26 people were assessed as being in urgent need of a mental health bed but none were available.
Two months later, 19-year-old Gabriel Lang, unable to get into Fremantle Hospital Mental Health Service because it was closed, waited a “couple of hours” at the hospital’s Emergency Department but eventually left in a state of agitation. Later that night he allegedly fatally stabbed his mother in her White Gum Valley home. He also allegedly injured her partner, his sister and himself. He has pleaded not guilty to charges of murder and attempted murder.
In July 2015, a patient crisis at Graylands Hospital forced the closure of five beds at that facility, precipitating a week-long ‘code yellow’ during which about 20 mental health patients were kept in EDs at Royal Perth and Sir Charles Gairdner Hospitals for long periods.
That week, a young woman told a stark tale of her struggle to care for her mentally ill brother, hospitalised 12 times in the first half of the year alone, and of her experience with a system “skewed to allow suffering”.
Just over a week ago, WAtoday reported SCGH’s ED was again in crisis, with a flood of 16 mental health patients, including “high-risk” patients, left languishing in the ED.Five patients ended up being held for between 20 and 64 hours each, with the 64-hour “high-risk” patient becoming so agitated that a senior ED staffer said they rang police to ask for increased patrols.
“We cannot maintain the four-hour rule,” the staffer told WAtoday.
“Every day we’re fighting with Mental Health to take ownership of their own patients and the ED is a default for them to manage their caseloads.
“These patients are here for hours or days on end.”
After the story was published those patients were found beds within two to three hours. Minister Morton said the north metropolitan area was experiencing an “unexpected high level of demand for authorised and secure mental health beds” and was doing all it could.
It seems worth asking: should the unexpected loss of a handful of beds, or arrival of a handful of patients, throw the system into emergency mode several times in a year? Shouldn’t it have shock absorbers, as it were? And when the government says everything is business as usual, but medical professionals contact the media in desperation to say that everything is not, who should we believe?
The system: a snapshot
About 12,000 people a year check out of a mental health bed in WA each year, Ms Morton has said, and about 20 people with mental illness present at the SCGH ED each day.
The Royal Australian College of Psychiatrists WA last year told the parliamentary inquiry the state needed to double its psychiatrists and add 70 acute inpatient beds.
In the two and a half years since it was elected the government has opened many beds in the state but closed (or “reconfigured”), many others.
New beds added (43)
- 20 of the 30 new beds @ Fiona Stanley MHU (10 yet to open)
- Seven at Albany Hospital
- Three at Broome Hospital
- Five at Joondalup Hospital
- Eight at Mental Health Observation Area at SCGH ED (two are chairs)
*Six Hospital-In-The-Home beds, where medical and nursing staff provide hospital-level care in the home where appropriate, have also opened
Beds “reconfigured”
- 38 Hospital-in-the-Home beds opened (offsetting closure of 32 at Graylands, 8 at Selby Older Adult MHU)
- Intensive youth community treatment program opened (six child and adolescent beds at Bentley Hospital closed)
- 30-bed Mental Health Unit at SCGH opened mid-year (replaced 36-bed mental health ward).
*Further bed reconfiguration between sites to occur when Midland Health Campus opens
Importantly, the new SCGH MHU has 12 secure beds, meaning the hospital is now “authorised” to deal with involuntary patients.
Ms Morton said this was a “game-changer” for the system, improving flow through the ED by reducing the need for transfers to Graylands.
“We’ve had terrible situations at SCGH before in which people have come into the emergency department at one of the biggest teaching hospitals in Perth, one of the busiest emergency departments, and if someone required involuntary care they can’t stay there they’ve got to wait till they can be transported … sometimes up to 30 hours,” she said at the time.
Asked why this was still happening despite the new unit, she said there was a high level of demand in the area at present and the unit had not been open long enough for its impact on patient flow to be assessed.
Average time from arrival in the ED to bed allocation was four hours, but presentations were not rhythmic or predictable.
“Spikes in activity place extra demand on services, and there will always be isolated cases that spend many hours within the ED,” she said.
Is it enough?
The mental health system’s resourcing is good but favours the lower end of the spectrum – people basically functioning, but struggling with anxiety or depression and often relying on community and non-government organisations, Australian Medical Association Western Australia president Michael Gannon has said.
“That’s not to diminish the importance of looking after those patients. That is important,” he said.
“But at the sharp end, people with chronic psychotic illness or acute psychiatric episodes which may or may not relate to alcohol and drugs, plus acutely suicidal patients, their interface with the system … is through hospital EDs.
“There is not enough emphasis on the important work psychiatrists do in the Perth hospital system for those acutely sick patients.”
He said the population was growing and doctors were seeing more and more mental health problems. Complex causes made it hard to explain, but alcohol and drug abuse, particularly methamphetamine abuse, were undoubtedly a factor.
He said a lack of beds was overloading the emergency system but the government would not admit it.
“It is real and at the same time we are closing acute mental health beds,” he said.
“That is putting massive demands on doctors, nurses, other staff in EDs, compromising their ability to look after other patients … with the system not having the capacity it needs, you are ending up nursing people in an environment detrimental to their mental health.
“EDs are busy places. They are loud, there is always a lot of activity, a lot going on. It is the last place that someone who needs to be calmed down should be nursed for any length of time.
“The government needs to start looking at ways to increase capacity in the mental health system. They can’t just keep asserting that everything’s OK.”
Minister Morton said in a July interview that bed numbers should not be such a focus.
“People have to have good services in the community to keep them out of hospital and that’s why we’re focusing so much on the subacute facilities, the new sorts of beds that are in the community where people can access those services at an earlier stage in their illness and not require the very high intensive acute inpatient unit,” she said.
Complicating this argument is the testimony of the senior staff member at SCGH ED, who told WAtoday patients were coming to ED because the community facilities could not handle their level of illness.
Newly appointed federal Health Minister Sussan Ley told Radio 6PR on Monday that there were too many “crossovers” between federal and state mental healthcare systems.
Hospitals were a state responsibility while primary care, including GPs and other community services, was usually federal, but community mental health was run by the state, and help lines and websites partly funded by numerous organisations.
“It’s fragmented, disjointed, it doesn’t make sense. If you’re perfectly well, you can’t work it out let alone if you’re pretty sick,” she said.
“You can step away from hospital and it’s as if … no one knows you’ve been unwell. There’s no follow-up, there’s nowhere to go, you’ve perhaps been admitted with a suicide attempt, you’ve come out and a week later you’re feeling absolutely desperate again.
“Even [facilities] that are well-resourced don’t have much in them. Put simply, as one psychiatrist said to me, if something can be picked up and thrown, it often will be. People hurt each other.
“Overall, they’re awful places. They are staffed by magnificent people. The doctors and nurses who work in these areas are amazing caregivers but it’s a very, very difficult area of practice.”
She said many of our facilities were taken up by ice users with psychotic episodes, meaning people with chronic disease could find it harder to get a place.
“I’ve talked recently with a parent who lies in the doorway of their adolescent child’s bedroom, because they know some time during the night, they’re going to get up and try to leave the house and they are not safe,” she said.
“They can’t find a secure facility for them. I feel desperately for the families who watch, often helplessly, as a person very close to them descends into a type of hell that they can’t save them from.
“We have to do better.”
Whose problem?
Dr Gannon said EDs were not to blame.
“Every time we raise the loss of real beds at the acute end of the spectrum, we get told that we’re wrong. Is this easy? No it’s not, but it could start with the Minister for Health having greater investment in a problem for his hospitals and for both arms of the government to stop shooting the messenger,” he said.
He said while the government had done well in creating Australia’s first mental health minister, she and Health Minister Kim Hames needed closer collaboration.
“A mentally ill person is more likely to have other health problems and they’re more likely to have alcohol and drug problems. The idea you can separate out mental health from the rest of the health system shows a failure of understanding,” he said.
“When you’ve got patients in the ED for 64 hours that makes any discussion on the four-hour rule obsolete.”
Health Minister Kim Hames declined to comment on WAtoday’s most recent story about the SCGH , deferring to Minister Morton, perhaps an illustration of that point. But he did consent to comment for this story.
He said he and his department worked closely with Ms Morton and the Mental Health Commission, giving the example of the opening of the Mental Health Observation Area at the SCGH ED.
“At the same time we recognise that often the treatment proven to work best is to manage a patient’s progress to a point where he or she can move back to a familiar home environment,” he said.
Minister Morton also defended the relationship, saying she and Dr Hames clearly understood their roles and responsibilities and the government had already recognised the importance of mental health with the creation of the Commission and her portfolio.
She said they went through the same government processes that occurred when any issue required input from both portfolios. She met regularly with the Health Department Director General to discuss service delivery and with the Commissioner to discuss policy and purchasing. The DG and Commissioner also met regularly, as did all three of them, and the Commissioner met with the chief executives of area health services (which control hospitals) every three months.
The system doesn’t need more meetings, then. Or more money.
Wait. What?
There is one thing they all agree on – there is no more honey in the pot.
Dr Gannon said with health now responsible for 30 per cent of all state government spending, money needed to be spent “smarter”.
“Governments spend their money smartest when they listen to clinicians on the front line, and their clinicians who work in EDs are telling them there’s a problem,” he said.
Dr Hames said WA had some of the highest paid clinical staff in Australia and was also delivering hospital services at a cost significantly above the national average, which was not sustainable.
“Part of the efforts to increase efficiency have been the introduction of the four-hour rule and the new policy to reduce ambulance ramping. I’m very pleased to say these initiatives are working,” he said.
Minister Morton said the Mental Health Commission’s budget in 2015-16 increased 5.4 per cent over the previous financial year and this funding would go to public mental health, non-government organisations and drug and alcohol services.
But the Commission was now finalising the WA Mental Health, Alcohol and Other Drug Services Plan 2015-2025, which recognised that in the “current difficult fiscal environment” changes to the system would need to be funded largely through “re-configuration” of existing resources.
WA Police Commissioner Karl O’Callaghan also announced this year the the government was considering giving 24 WA nurses limited police powers as part of proposed mental health crisis intervention teams, allowing them to help police who encountered mentally ill offenders.
The police, Mental Health Commission and Health Department are still ironing out the details but Mr O’Callaghan’s office confirmed that they now knew nurses would in fact not need any new legislated powers to carry out such work.
For its part, Ms Ley said this week, the federal government was promising a major structural reform of its own system. The federal Mental Health Commission had conducted a review whose final recommendations the government was now translating into policy, which she would announce by the year’s end.
Part of the reform would include talking to the states about health and hospital funding. Perhaps one day the divisions of state and federal responsibility areas would change, but that would require constitutional change, a lengthy process. Meanwhile, the federal government continued to fund about 40 per cent of the states’ public health systems.
She said the Commission report itself had said more money was not the answer.
“It talked about the fragmentation, the disjointedness … the unhelpfulness of the system,” she said.
“It didn’t say that we need more money which is, I suppose, for us, an opportunity, because in the current budget, there’s not a lot more money to be had.
“We actually can do much better with the dollars that we do have if people worked together and we designed a system that is built for the patients. Everything I do in health policy I say, build this for the patients, not for the program delivered, not for the services, not for the public servants, not for the ministers. It’s for the patients.”
“What I can tell you is that the approach will be more about what suits the individual person.
“It is a difficult system to fix, but it’s not impossible to make it much better – quickly.”
If you are having a mental health crisis or know someone who is, call Lifeline on 13 11 14.