PART SIX: ANALYSIS OF SUBMISSIONS AND FORUMS AGAINST THE NATIONAL STANDARDS FOR MENTAL HEALTH SERVICES

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6.1 New South Wales

• 6.1.1 STANDARD 1: RIGHTS
• 6.1.2 STANDARD 2: SAFETY
• 6.1.3 STANDARD 3: CONSUMER AND CARER PARTICIPATION
• 6.1.4 STANDARD 4: PROMOTING COMMUNITY ACCEPTANCE
• 6.1.5 STANDARD 5: PRIVACY AND CONFIDENTIALITY
• 6.1.6 STANDARD 6: PREVENTION AND MENTAL HEALTH PROMOTION
• 6.1.7 STANDARD 7: CULTURAL AWARENESS
• 6.1.8 STANDARD 8: INTEGRATION
• 6.1.9 STANDARD 9: SERVICE DEVELOPMENT
• 6.1.10 STANDARD 10: DOCUMENTATION
• 6.1.11 STANDARD 11: DELIVERY OF CARE
• 6.1.12 STORIES OF HOMICIDE AND SUICIDE IN NSW

ANALYSIS OF SUBMISSIONS AND CONSULTATIONS FROM NEW SOUTH WALES AGAINST THE NATIONAL STANDARDS FOR MENTAL HEALTH SERVICES

In summary, information presented in this section was gathered from 82 submissions (see Appendix 8.3.1) and presentations made community forums attended by approximately 163 people (see Appendix 8.1). A draft copy of this report was sent to the Premier and Minister for Health for comment. An analysis of the response from the New South Wales Government (reproduced in Appendix 8.4.1) and an overall review of mental health service delivery in New South Wales is contained in Part 2.7.1.

6.1.1 STANDARD 1: RIGHTS

The rights of people affected by mental disorders and / or mental health problems are upheld by the MHS.

 Under this Standard, submissions and presentations indicate concerns about:

• non-compliance with relevant instruments protecting the rights of people with mental illness;
• lack of information about treatment options;
• problems with the complaints process;
• consumers not being treated with dignity and respect;
• rights of people with mental illness in the criminal justice system;
• lack of access to advocates;
• lack of access to interpreters; and
• ministerial discretion and the rights of people with mental illness.

I would like to know if it is possible to take class action against NSW Government on behalf of the mentally ill people and their carers on the basis of discrimination demonstrated by the loss of big psychiatric hospitals such as Gladesville and Rozelle without proper compensation by provision of equivalent community and general hospital based services.

(Clinician, New South Wales , Submission #25)

6.1.1.1 Non-compliance with relevant instruments protecting the rights of people with mental illness

Concerns were expressed that staff of the MHS are not complying with relevant legislation, regulations and instruments protecting the rights of people affected by mental disorders and/or mental health problems (Standard 1.1). Included in the notes and examples for Standard 1.1 are: The Australian Health Ministers' Statement of Rights and Responsibilities, the UN Prinicples on the Protection of People with a Mental Illness and Improvement in Mental Health Care, departmental codes of conduct and mental health legislation.

Why in 2004 are our loved ones still suffering after policy documents from fancy government watchdogs have been released? Why aren't our loved ones receiving the same quality of care as people with physical illnesses? Are they not worthy of treatment? Where is the concern? There are huge problems with the system and some of the staff within the system. There is physical and sexual abuse still occurring. Why do we still use seclusion where there are no toilets, no water?

(Carer, New South Wales , Parramatta Forum #1)

...the basic human rights of people living with a mental illness are still being ignored. What about the voiceless sufferers of people with a mental illness.

(Carer New South Wales , Sydney Forum #2)

It must be recognised that the patient is the most disempowered person, the one whose input is most likely to be disregarded and put down as a symptom. As such it is necessary to ensure their rights.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales , Submission #349)

The Indigenous Social Justice Association (ISJA) and Justice Action (JA) also expressed concern regarding the frequent assumption that people with mental illness lack the capacity to consider matters, give opinion or give directions and that this lays the basis for many rights being denied:

We believe that it is vital to respect the patient as a person. It should never be assumed that the person is incapable of considering a matter, forming an opinion and giving direction regarding the matter. This includes who is privy to information and who may be involved in admission, treatment, and discharge, in terms of Health and non-Health persons and the interaction of the two. There is generally a presumption that any patient with psychiatric disability lacks capacity. This is untrue. It is also untrue that a lack of capacity regarding one issue means that the patient may be regarded as lacking capacity in another or all issues. Issues need to be looked at on a case by case basis.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

6.1.1.2 Lack of information about treatment options

Concern was expressed that mental health services are not providing consumers and their carers with information about available mental health services, mental disorders, mental health problems and available treatments and support services. Standard 1.8 states: 'The mental health service provides consumers and their carers with information about available mental health services, mental disorders, mental health problems and available treatments and support services'.

This is of serious concern on many levels with regards to consent, choice, the right of a person to know about their illness and the treatment plan (and any side-effects) and for carers to be informed regarding what is and will be happening and how they best support the consumer or access support for themselves. The following statement by a consumer at the Sydney forum indicates that despite frequent contact with the mental health service, very little information was provided about treatment options to allow the consumer to realise her range of options and elect to receive treatment in the least restrictive setting:

I have had 4 acute episodes but it was only during the last one that I found out that I could be treated at home if I had a support person.

(Consumer, New South Wales, Sydney Forum #11)

The worker left absolutely no information - not even a business card. No information was given about community services ... The worker did not arrange any support services or give any information about them.

(Carer, New South Wales, Submission #48)

6.1.1.3 Problems with the complaints process

Carers who had used the complaints procedure reported feelings of anger with the process, of being ignored or their concerns trivialised or being fearful of losing everything they had. The descriptions provided by carers did not accord with a complaints procedure 'easily accessed, responsive and fair' (Standard 1.10). Failure to have in place a system which allows consumers and their families and carers to make complaints confidentially and ensure that complaints procedures are adhered and responded to weakens this right and fails to provide a mechanism by which to 'improve performance as a part of a quality improvement process' (Standard 1.12). Comments presented via submissions indicate that the complaints procedure is currently obstructive and futile. The complaints process does not allow for the identification of single or systemic failures and thereby does not allow for personal redress or systemic improvement. The following extracts from a number of submissions illustrate some of the frustration experienced by people when dealing with a dysfunctional system:

We have lost our son ... There has not been a hearing yet, which we made a statement to say we wished to be present at. The Dr that was head of the [X] Dept made a comment to us as we left to something of the effect that we shouldn't pursue the matter any further as not having a lot we could lose all that we have. Our son was told he could not leave as he was too ill and was on 24 hour surveillance, and this happened ... Dr [Z] ... [h]e felt there was not enough done. I feel the medication he was on made him do what he did.

(Carer, Mother, New South Wales, Submission #135)

We had made a detailed complaint in writing to Mr [Y] (General Manager, X Hospital) on 23 December 2001 and were unsatisfied with his response which was inaccurate, glib and condescending.

(Carers, Parents, New South Wales, Submission #106)

My wife made a formal complaint about [nurse]'s behaviour, but there was no response from the hospital.

(Carers, Parents, New South Wales, Submission #106)

The health service will only flex a muscle when it feels threatened by actually appearing before a coroner's inquest or being sued.

(Consumer and Consumer Advocate, New South Wales, Submission #8)

There is not enough access to legal aid for those with a mental illness in terms of ongoing support. There seems to be a disparity in what can be accessed by those with a mental illness compared to those without a mental illness.

(Clinician, New South Wales, Broken Hill Forum #20)

People have the right to legal aid. I know from my husband that consumers have been refused legal aid and are put on community treatment orders because of their mental illness.

(Clinician, New South Wales, Broken Hill Forum #19)

I applied under the Freedom of Information Act to get access to files to lodge a complaint - we have been waiting for two months and haven't received any medical files. The mother recently suffered a stroke her sister is caring for her.

(NESB Consumer Advocate, New South Wales, Parramatta Forum #8)

During December 2001 and January 2002, we had a number of discussions and conferences with the MHU [Mental Health Unit] Psychiatric Registrars and with Dr [Y], Director MHU. Our experience with these people was that no follow-up occurred with some issues that we raised, treatments recommended by them were not carried out because they did not appear in the treatment notes, and official complaints were ignored.

(Carers, Parents, New South Wales, Submission #106)

I also wrote to the Health Complaints Commission who felt an internal investigation was warranted. Apparently as a result we have had the business cards of the clinic changed, as the number there was misleading to patients. [X] called it for help upon discharge and the phone had rung in the patients lounge and was answered by a patient. He wanted help and no-one was there. Also I think other smaller things have been changed with regard to patient care especially after an attempt at suicide. Not much in the scheme of things.

(Carer, Wife, New South Wales, Submission #126)

6.1.1.4 Consumers are not being treated with dignity and respect

Overall, many carers and consumers expressed concern that during their involvement with the MHS they were treated with disrespect and as citizens whose rights as described under the National Standards were ignored.

Consumers have a right to be treated with dignity and respect. It is our view that some staff are not acting appropriately in the way in which some consumers, carers and agencies are being treated.

(Eastern Area Interagency NSW, New South Wales, Submission #100)

Some people are transported around in paddy wagons for days because there's nowhere for the police to take them. Some people are held in seclusion for days on end for the same reason. Where is the humanity in this? People who are on community treatment orders are required to turn up at police stations to get their injections.

(Consumer, New South Wales, Parramatta Forum #5)

My wife and I are appalled at the social injustice and undignified treatment to which we and our daughter were subjected during our daughter's 35 days in the MHU.

(Carers, Parents, New South Wales Submission #106)

By 15 December 2001, our daughter had developed severe oral thrush, her tongue being swollen preventing her from swallowing and talking without great distress. Unbelievably, her meals still comprised solid food (which she could not eat); this situation led to her subsequent malnutrition and severe dehydration which resulted in her losing 12 kilograms and being transferred to medical ward 2 East on 4 January 2002 for prompt life-saving intravenous and naso-gastric treatment ... We observed that MHU staff has no time or interest in addressing anything other than our daughter's mental state. Also on 15 December 2001, my wife saw our daughter drinking the toilet water to help relieve her dry and thickly-coated tongue, mouth and throat.

(Carers, Parents, New South Wales. Submission #106)

My brother suicided in a hospital ... My brother is just an example of what will happen to others who are failed by the system. People are placing too much faith in institutions - people need access to good quality community care without having their human rights abused. My brother had care at Rozelle but he didn't really qualify for that catchment area so he then had to go back to St George but there wasn't anything for him to do there.

(Carer, Sister, New South Wales, Sydney Forum #7)

After 4 January 2002 when our daughter had been transferred from the MHU into medical ward 2East, she was immediately treated by the staff as a whole person with dignity, respect, compassion and empathy. We observed that the medical ward staff was a professional caring team at all times, even when our daughter was a handful They accepted the challenge with care, diligence, resourcefulness and a great team effort which achieved a great result in a short time in comparison with the five weeks that our daughter was in the MHU where she deteriorated badly. As parents, we are grateful for the clear concise and accurate information the medical ward team offered us, keeping us informed and assured that our daughter's medical treatment was on-track.

(Carers, Parents, New South Wales, Submission #106)

The clients ... are the ones who end up 'falling between the gaps'. Even of their chosen lifestyle is non-conformist or they are 'difficult clients' they are still human beings who are entitled to be treated. And treated humanely.

(Walgett SAAP Services, New South Wales, Submission #63)

They did not send a letter of introduction with a request for contact prior to the first visit of three people to the home which came as a surprise to the client [aged person] and carer. No reason was given for this ... At no stage did the worker [aged care assessment team] advise the client [aged person] when they would be arriving. They just had to let them in ...

(Carer, New South Wales, Submission #48)

He was supposed to be sent to a hospital with a psychiatric ward but instead he was sent to Silver Water jail which does not have a psychiatric ward. At the jail he was sent into the general population area with no toothbrush, no glasses, no hearing aid. That is where he stayed for 2 months. We spent two months trying to get him his glasses and hearing aid

(Carer, Mother, Victoria, Footscray Forum #8)

6.1.1.5 Rights of people with mental illness in the criminal justice system

The Indigenous Social Justice Association (ISJA) and Justice Action (JA) raised concerns with regard to the rights of people with mental illness in the criminal justice system and the need to be particularly vigilant about protecting the rights of these consumers and their access to treatment and support services. Carers also raised concerns about conditions and treatment received by their children with mental illness while in prison:

They are in a highly restricted environment, have no choice in provision of service, have far reduced access to their support network, have even greater problems in accessing any complaint or oversight body and in allowing such bodies to examine information that they request to be examined.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

Prisoners must also be able to nominate friends / family / advocates as per below and have access to their information and control over who is allowed to have it like any other person.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

In May 2001, as a consequence of that inadequate treatment, he was charged with malicious damage by arson and in April 2002 was found not guilty by reason of mental illness. From May 2001 until June 2003 our son was incarcerated in appalling conditions at Long Bay Prison Hospital. His behaviour throughout that period was exemplary. During all of that time, he was locked for at least 11 hours a day, and often longer, in solitary confinement in a prison cell and was not allowed to have a TV in his cell. He was frequently hungry, due to the poor quality of the food provided.

(Carers, Parents, New South Wales, Submission #75)

We have been shocked by the use of prisons as surrogate mental health care and treatment facilities in NSW. We do not believe that this is an acceptable option in 2004. Furthermore we consider it is in contravention of the United Nations Declaration of Human Rights 1948.

(Carers, Parents, New South Wales, Submission #75)

Section 32 of the Mental Health (Criminal Procedure) Act 1990 (which commenced 14 February 2004) provides magistrates with the option to divert people with an intellectual disability or mental disorder into the 'human services sector' rather than convicting them of a criminal offence. Walgett SAAP Services noted its concern that people with a mental illness have been inappropriately incarcerated because they have been unable to get the documentation necessary to prove their illness:

Local solicitors have advised that it is difficult having client matters dealt with under s32 of the Mental Health Act due to the lack of necessary psychiatric reports. Consequently many clients are dealt with in the prison system.

(Walgett SAAP Services, New South Wales, Submission #63)

6.1.1.6 Access to advocates

Concern was expressed that consumers are not being made aware that they have a right to have 'an independent advocate or support person with them at any time during their involvement with the MHS' (Standard 1.6). This has resulted in support people, including nominated service providers, explicitly being refused involvement when consumers have specifically requested their co-attendance and support:

We have also found problems with the system's recognition of independent advocates, who having been specifically requested to act of behalf of a patient regarding a certain matter, are denied the ability to do so. This even occurs when the request has been in writing - demands are made for the request to be rewritten in a standardised format. This causes frustration in the patient and delay in resolving a problem. The form suggested above plus an expanded ability for friends, family, people in other close relationships and advocates to rapidly contact the Official Visitor and have them look into problems will also assist in this area of concern.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

We propose that communal self advocacy organisations be formally recognised and allowed to do individual patient advocacy on request, and systemic advocacy regarding the issues affecting their members.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

Appealing for a shy person with mental issues is extraordinarily difficult. At least there are hospital visitors for people in hospital. It would seem that there should be a system of advocacy whereby of there is an at home visiting by the ACAT [Aged Care Assessment Team] team there should be an independent advocate who makes contact - both for the carer and the client - who facilitates appeals and ensures the individuals fully understands the process. Unfortunately the client may not appeal because they just don't want the hassle - it is too much for them - there needs to be some way clients and carers can make their views known and taken into account.

(Carer, New South Wales, Submission #48)

6.1.1.7 Access to interpreters

For people who have a hearing impairment or speak a language other than English, access to mental health care is further complicated by communication and cultural barriers. These barriers may make it difficult for the consumer and their family and carers to understand mental disorders, mental health problems and available treatment and support services and how to navigate the system. In many cases a person may be socially isolated or reluctant to have family or friends involved as carers or act as an interpreter for reasons of confidentiality or stigma. Evidence presented at forums and submissions indicate that many consumers from a non-English speaking background (NESB) are not made aware of their rights and responsibilities in either a written or verbal manner as required by Standard 1.3 (e.g. written material in their language or via and interpreter). This failure to appropriately inform people of their overall rights means that consumers may be specifically unaware of their right to have access to an accredited interpreter (Standard 1.7). Additionally, it appears that some health professionals are either not aware of the right of consumers and carers to have access to accredited interpreters or they are specifically denying consumers and carers this right. The following quotes from a number of the community forums serve to illustrate these failures:

We tried to set up a telephone interpreter service in mental health services for the hearing impaired but we had no success. Services are not budgeting for interpreters. There are only 2 F/T hearing impaired community workers for the whole of NSW.

(Disability Community Worker, New South Wales, Parramatta Forum #2)

The use of interpreters is still a big problem. The services are not using interpreters when they should be.

(Multicultural Mental Health Worker, New South Wales, NESB Parramatta Forum #9)

People assume it's not their right to have an interpreter present. We've had dealings with services that simply don't inform people of their right to have an interpreter present. It can also be costly for the client. Phone interpreters were free for just five years.

(Anonymous, New South Wales, NESB Parramatta Forum #13)

Services are saying they don't work with interpreters. Bankstown will but Parramatta won't.

(Service Provider, New South Wales, NESB Parramatta Forum #21)

6.1.1.8 Ministerial discretion impeding rights

Carers expressed concern regarding Ministerial discretion when reviewing Forensic Orders and when the Mental Health Review Tribunal has made a decision regarding changes to treatment orders:

The Minister is sitting on a request for a consumer to go home even after the Mental Health Tribunal has approved his release.

(Carer, New South Wales, Parramatta Forum #1)

During the period of our son's Forensic Order, we have not been satisfied with the 'due process' of administration of conditions of that order. The requirement that the NSW Minister for Health approve these conditions means that the process is inappropriately politicised. Decisions about transfer and leave for patients, seem to be made to appease community attitudes about mental illness and violence, which are steeped in stigma, rather than in the best interest of the patient.

(Carers, Parents, New South Wales, Submission #75)

6.1.2 STANDARD 2: SAFETY

The activities and environment of the MHS are safe for consumers, carers, families, staff and the community.

...the increasing service resource crisis presents significant threats to the rights of mentally ill people. This occurs through compromising safety and increasing the risk of sub-standard treatment, undermining centres of clinical academic excellence, increasingly marginalising those with mental illnesses, and through a tendency when addressing clinical problems to rely increasingly on administrative and legal solutions rather than clinically led solutions. The adverse factors combine to make front-line public mental health professionals an endangered species."

(Public Sector Psychiatrists, New South Wales , Submission #297)

Under this Standard, submissions and presentations indicate concerns about:

• excessive focus on security;
• safety concerns for consumers in hospital settings;
• safety concerns of staff; and
• inadequate treatment and support services to ensure the safety of consumers, carers and the community.

6.1.2.1 Excessive focus on security

The NSW Police Association expressed a broad range of concerns with the system of mental healthcare in NSW. In particular, the Association highlighted the large number of people with mental health and drug and alcohol problems needing to be dealt with by the police. They regarded this as a clear failure of the mental health system:

A report released in June 1998 on police shootings showed that more than half the 41 people shot dead by Australian police officers since 1990 were under the influence of drugs or alcohol, and one third were depressed or had a history of psychiatric illness - a clear indication that the system is failing.

(Police Association of New South Wales, New South Wales, Submission #59)

Consumers, carers, NGOs and others expressed concerns with the increasing focus and emphasis on security. Many considered these approaches to superficially address safety in a way that increased fear and intimidation and dehumanised those in 'care':

Some of these security measures convey to the public that the people behind the wire are animals that need to be constrained.

(Carer, New South Wales, Parramatta Forum #4)

Everything is so security driven now - this is a real problem. There's increased gates and increased security.

(Consumer Consultant, New South Wales, Parramatta Forum #9)

Consumers are really intimidated by all the increased security. Even during tribunal hearings there might be two security guards present. Hospitals are not supposed to be prisons.

(Anonymous, New South Wales, Parramatta Forum #10)

It is not uncommon for people suffering a mental illness or acting irrationally, to feel threatened if confronted by a police officer ...

(Police Association of New South Wales, New South Wales, Submission #59)

6.1.2.2 Safety concerns for consumers in hospital settings

Standard 2.3 states: 'Policies, procedures and resources are available to promote the safety of consumers, staff and the community'. Clinicians and carers expressed concern that policies and procedures were not in place to promote the safety of consumers, and that often this was due to a lack of resources:

These problems jeopardise patient safety. Every day, there are knife-edge situations that generally do not end in disaster, only because of the extraordinary efforts of frontline personnel. It is difficult to act in the patient's best interest when institutional pressures are so great.

(Public Sector Psychiatrists, New South Wales, Submission #297)

We observed the MHU staff working under considerable pressure, their services being under-resourced and their numbers inadequate for their patients' safety. We are hesitant to single out particular staff, but we believe that individually it is their responsibility to practice appropriate duty of care and nursing similar to that demanded in hospital medical wards.

(Carers, Parents, New South Wales, Submission #106)

My brother, like many others with a mental illness doesn't have a voice. My brother suicided in a hospital - I came from a modest European background. My parents believed that we would get care ... Hospitals need to be safe - we need to make our hospitals places where it is not easy for people to die from suicide.

(Carer, Sister, New South Wales, Sydney Forum #7)

Around 14 December 2001, my wife saw that the hand basin in the MHU female toilets had been removed leaving the taps to flow directly onto the floor. Patients were still using the taps, in their altered mental state. A month later, my wife noticed that nothing had been done to fix this situation. We believe that this is negligent maintenance and also an OH&S issue, apart from giving carers no faith in the basic competence within the MHU.

(Carers, Parents, New South Wales, Submission #106)

Over three weeks from 9 January 2002, our daughter had a series of ECTs [Electro-Convulsive Therapy]. On 23 January 2002, we observed that no MHU staff accompanied her to the theatre. This was the second time that she was unaccompanied by MHU staff, whom we were told had this responsibility as duty of care, and this MHU delinquency angered the medical ward and theatre staff. We observed on this same day that MHU sent a patient to theatre who had had a drink, and she was rejected by theatre staff.

(Carers, Parents, New South Wales, Submission #106)

However, for [public hospitals] to be safe there needs to be more staff because understaffed, frantic places are ripe for further abuse. During these two stays in hospital in Sydney I saw three other patients assaulted by fellow inmates and one of them was not even believed when she tried to report it to staff. I was really angry on her behalf but I said nothing because I thought I might get a personality disorder back on my file if I attempted to stand up for her.

(Consumer, New South Wales, Submission #327)

6.1.2.3 Staff safety concerns

Concerns were also raised about current policies, procedures and resource allocation to ensure the safety of staff:

I now find it stressful being on call for a weekend. But the mix of patients has changed too. They are on the average more aggressive, more violent.

(Anonymous, New South Wales, Submission #303)

I want to talk about an incident that occurred recently which should indicate to you some of the problems we're faced with in the NGO sector. Two of my nursing staff were leaving work at night and were approached by a client. The client was upset at not being able to access accommodation because he was considered to be non-compliant with his treatment. He threw punches at the nurses and they had to run for their safety. One of the nurses managed to get her mobile phone out and phoned the police and then taken to a secure mental health unit. Within ½ hour he was assessed as being intoxicated and not scheduled - he was released onto the streets and was back outside our service wanting accommodation.

(Clinician, New South Wales, Sydney Forum #3)

Public attention rightly focuses on patient safety but not sufficiently on safety of mental health personnel, with regular assaults on staff being ignored in the media. Current services were not designed to accommodate highly dangerous patients or persons in social crisis who are violent. An overwhelming focus on safety issues ultimately will degrade the humanistic base of psychiatry, with fear driving a wedge between patients and personnel.

(Public Sector Psychiatrists, New South Wales, Submission #297)

Safety for staff is very important, but can be assured by other means (working in pairs to home visit unknown people, electronic safety and communication equipment, returning to a common community base at nights and on weekends, insisting on police involvement if there is the slightest hint of possible danger with ensured response dictated by memoranda of understanding with police, by not allowing any staff to see people in community centres alone at night, etc.).

(Clinician, New South Wales, Submission #351)

Ultimately, OH&S and economy-of-scale arguments can be extended to banning all community health centres and all home visits. The appropriate path is to make community work as safe as possible, to screen and divert most assessments and initiation of treatment away from Emergency Departments, and then use Emergency Departments in exceptional, highly ambiguous or emergency circumstances only, or to assess mixed medical/psychiatric emergencies.

(Clinician, New South Wales, Submission #351)

It is not too difficult in reality to accommodate OH&S concerns while maintaining community based services. We could be forgiven for suspecting that this concern is simply a screen for the dominant drive to economically rationalize services, and to realize assets occupied by mental health services for general health purposes.

(Clinician, New South Wales, Submission #351)

As well as the serious implications this crisis has for patients, there are very real and unacceptable consequences for staff. In addition to the obvious risks associated with safety and aggression, there is the deleterious psychological impact on staff constantly frustrated in their attempts to deal humanely with these people in a system that is patently incapable of responding adequately to demand.

(Mental Health Workers Alliance, New South Wales, Submission #325)

6.1.2.4 Inadequate treatment and support services to ensure the safety of consumers, carers and the community

As documented elsewhere in this Report, consumers, carers and staff also raised concerns about their inability to access treatment and support services during times of crisis, including when at risk of harm to self or others.

When released from hospital, they could do no more for him the hospital said, he proceeded to harass his wife. [X] was arrested and charged and sent to jail ... he appealed and was out in five weeks. They did not let his wife know this ... Last resort, he got a sledge hammer and at 4.30 am ... 2004 smashed the back door of [wife]'s house, threatening to kill himself with knives he had, locking his small daughter in her room and held wife all day until Police arrived and arrested him. ... Also his wife and children under constant fear, how do they cope, all having counselling now, how safe are they? All the mental hospitals tried to help but after some time just sent him home on medication when they were unable to succeed, hoping he would survive.

(Carer, Sister and Brother-in-Law, New South Wales, Submission #108)

There have been incidents where Mum was not covered by a CTO (Community Treatment Order), which meant my mother (under partial care) took to living on the streets and could not be picked up off the streets, even if it was for her own good. I even once tried calling an ambulance, when I saw her asleep on a bench hoping they would take her, alas they couldn't. I was constantly beside myself and scared for her safety.

(Carer, Daughter, New South Wales, Submission #134)

On drugs, malnourished and sick, and mentally disturbed [X] was taken in by my mother who is an invalid pensioner suffering from early dementia. This led to inevitable breakdown of my mother's health as she could not cope with such a disturbed individual who was threatening violence.

(Carer, Sister, New South Wales, Submission #104)

[X] subsequently stayed with us for 10 days even though he was clearly very unwell and should not have been released from hospital. He seemed to be getting worse staying with us and constantly paced through the house day and night. [X] became very aggressive towards his family and had problems with his thought processes. His condition was obviously deteriorating rapidly and we were very worried about safety issues, both his and our own.

(Carers, Parents, New South Wales, Submission #198)

6.1.3 STANDARD 3: CONSUMER AND CARER PARTICIPATION

Consumers and carers are involved in the planning, implementation and evaluation of the MHS.

The other thing the NSW govt. is good at is holding inquiry after inquiy, establishing task force or select committee after each other - and all it is, is a big talk fest and we go around the same circle for the next 2-3 years or in Australia's case for the next 10 years.

(Consumer and Consumer Advocate, New South Wales , Submission #8)

Under this Standard, submissions and presentations indicate concerns about:

• consumers and carers not being heard; and
• a tokenistic approach by the MHS to consumer and carer participation.

6.1.3.1 Consumers and carers not being heard

Consumers and carers expressed concerns that they are tired of telling their stories and not being heard and they have no avenues to give voice to these views so that they can be heard in a meaningful way. According to Standard 3.2: 'The MHS undertakes and supports a range of activities which maximise both consumer and carer participation in the service'. However, for those consumers and carers who gave evidence either verbally or by submission, their experiences did not reflect realisation of Standard 3.2:

Families are fed up. They've told their stories over and over again. What assurance can I give them that this will be any different. We simply tell our stories yet again and nothing gets done to address the problem.

(Carer, New South Wales, Parramatta Forum #1)

As far as I am concerned there is enough talking and too many different organisations drawing up reports. People with mental illness need access to better care - we know what needs to be done.

(Carer, New South Wales, Sydney Forum #2)

I have had Schizophrenic since 1976 ... The system doesn't handle people with a problem like mine. Nobody cares - no one is standing up and saying these people need care.

(Consumer, New South Wales, Sydney Forum #4)

One consumer felt some progress, although a long time in coming, has been made:

We have to tell our stories time and time again - but there have been improvements - though it's been a long time coming! I think we're getting a good response now.

(Consumer, New South Wales, Broken Hill Forum #4)

6.1.3.2 Tokenistic approach to consumer and carer participation

Standard 3.3 states: 'The MHS assists with training and support for consumers, carers and staff which maximise consumer and participation in the service' and Standard 3.4 states 'A process and methods exist for consumers and carers to be reimbursed for expenses and/or paid for their time and expertise where appropriate'. One consumer advocate expressed concern that the mental health system is not committed to consumer participation and that many of the activities and positions are 'tokenistic':

Let's talk about consumers being employed within the mental health system. Yes, I'm a consumer employee and I get paid for 30 hours and work close on 48 hours each week ... What my gripe is that we have such minimal hours, that we simply cannot do half the stuff we're capable of and try to put into effect. More often than not we're not acknowledged as having any expertise, definitely expected (in my situation) to perform as a manger yet not paid accordingly. In other areas we're the most under utilised resource within a mental health service - and forget the voluntary crap - we deserve to be paid for a good day's work like any other person in the community.

(Consumer and Consumer Advocate, New South Wales, Submission #8)

One of the problems with consumer employment and consumer advocates is the vast dearth of an actual skills base. As a trainer in consumer advocacy for a state organisation, I constantly talk to consumers whose only criteria for having been employed in a consumer position is the fact they're a consumer. Even though some consumers are more sensitive to the situations that many consumers find themselves in - training is a must and understanding the very, very specific role of consumer advocacy is imperative.

(Consumer and Consumer Advocate, New South Wales, Submission #8)

Consumers are grossly under-utilised in Mental Health. There is a need for Independent Advocacy for Consumers by consumers.

(Consumer Activist, New South Wales, Submission #257)

6.1.4 STANDARD 4: PROMOTING COMMUNITY ACCEPTANCE

The MHS promotes community acceptance and the reduction of stigma for people affected by mental disorders and / or mental health problems. 

Social isolation & loneliness are guaranteed triggers of episodes of mental illness, substance abuse, self harm & suicide. This happens, and it happens all the time. And in rural and isolated communities, where resources are even more scarce, the problems are much worse.

(Consumer Advocate, New South Wales , Submission #153)

Under this Standard, submissions and presentations indicate concerns about:

• feelings of isolation;
• high levels of stigma and discrimination; and
• discrimination in employment.

6.1.4.1 Feelings of isolation

Consumers and carers expressed concerns about the stigma that still surrounds mental illness and how all too often this results in friends and other members in the community distancing themselves from the consumer and the consumer's family. This would indicate that campaigns and activities by the mental health system to address community acceptance and reduce stigma to date (Standard 4.1) have not been able to turn community attitudes around. A lack of community acceptance is a key barrier to people with mental illness (and their family members) being able to participate socially, economically and politically in society.

As the following quotes highlight, social isolation, feelings of being a burden on family and friends, are the real outcomes for many people:

Now as a survivor of suicide I find I could probably count my good friends on one hand. Many others I have known over the years either because of their own fears, or because [X] didn't die of an accepted death, have chosen to ignore my family and I. But I have never been ashamed of my husband. He fought it as only he knew how and to this day I'm proud of him.

(Carer, Wife, New South Wales, Submission #126)

There is no such thing as community care because the community doesn't care.

(Carer, New South Wales, Sydney Forum #5)

Many people with a mental illness simply don't survive - I've questioned what sort of society we live in when people stand around and laugh and take photos of the homeless. You can see it happening when you walk down the streets!

(Carer, New South Wales, Sydney Forum #5)

I think it is disgusting what the government have done to the mentally ill people of Australia. No one understands what is like to have a mental health problem in your family unless they are in the situation them selves. We live a silent pain. Ashamed. Embarrassed. In fear of our lives. Family destroyed. No one wants to help.

(Carer, Mother, New South Wales, Submission #90)

6.1.4.2 High levels of stigma and prejudice

Consumers and carers spoke of the high levels of stigma associated with mental illness and prejudice experienced by both people with mental illness and their families. Community awareness campaigns to increase understanding of mental illness, acceptance of people with mental illness and information about how to support people with mental illness and their families and carers were described as being critical. The following extracts show how stigma is still causing immense pain in the lives of people with a mental illness and in their lives of their families:

Stigma is also high in small communities like Broken Hill as people fear what they can't see. In discussions with legal advisors they have encouraged people not to disclose their illness. In addition, community attitudes are often dismissive of people with a mental illness.

(Consumer, Carer & Family Worker, New South Wales, Broken Hill Forum #23)

Stigma is a big problem in this community - people fear what they don't understand. I've experienced a change in body language of a specialist when they ask you what medications you are on. I've been told by a solicitor not to tell anyone that - sometimes our integrity is questioned just because we have a mental illness - we might be unwell but that doesn't mean we're stupid.

(Consumer, New South Wales, Broken Hill Forum #24)

We need to create more awareness in the community. My brother was 27 when he died - that is far too young - it's a waste of life. He was incredibly talented.

(Carer, Teacher, New South Wales, Sydney Forum #7)

Need to be aiming at inclusion not exclusion - I know of people who are banned from coming into shops because they have a mental illness. The stigma in our communities is still very bad. People are treated differently, badly because they have a mental illness.

(Carer, New South Wales, Sydney Forum #13)

There's an Indian saying - it takes a whole village to raise a child. Our younger generation don't always get that support from our "village". There are too many people trying to struggle on their own to make sense of the way things are for them.

(Carer, Mother, New South Wales, Submission #122)

Given the stereotype of mentally disordered people as dangerous, citizens often call upon the police to "do something" in situations involving mentally ill individuals, particularly when they exhibit the more frightening and disturbing signs of mental disorder.

(Police Association of New South Wales, New South Wales, Submission #59)

One major consideration is the release of offenders with a history of mental health problems. Mentally ill people face significant social pressures; the prejudices they encounter are even greater if they have both a criminal history and mental illness. People with a criminal history and mental illness can be over rated for their risk of violence. Therefore they can find it very difficult to access mental health resources in the community.

(NSW Department of Corrective Services, New South Wales, Submission #295)

Community stigma is also a problem. People with mental illness are picked on in the community, but there is no community support from services until these people become very unwell.

(Anonymous, New South Wales, Submission #156)

It is scandalous and a national disgrace that there is no significant commitment by governments and the prevalence of community unawareness and apathy. There has to be a national campaign similar to that for AIDS if mental health is to successfully obtain government support etc.

(Carer, Son, New South Wales, Submission #120)

Do you think that anyone cares about anyone with a Mental Illness. The government definitely do not, not even 3/4 of Australia or any where else for that matter.

(Consumer, New South Wales, Submission #70)

There is also the public perception of "suicide" being some sort of crime or punishment, not as it should be, of a perception of loving care and understanding. I must say however, that this was an accidental overdose, but nevertheless, the end result is the same.

(Carer, Mother, New South Wales, Submission #88)

Why is mental illness such a social taboo? If it were a medical condition, I'm sure there would be no end of help.

(Carer, Mother, New South Wales, Submission #88)

6.1.4.3 Discrimination in employment

Employment and a supportive workplace are seen as key factors in preventing the rapid escalation of mental illness and as being essential in the process of rehabilitation and reintegration into society after a period of mental illness. Standard 4.2 states: 'The MHS provides understandable information to mainstream workers and the defined community about mental disorders and mental health problems'. However, acceptance and understanding of mental illness seem to be lacking in the workplace and, according to submissions received and evidence given at many of the forums, discrimination and high levels of stigma are still prevalent in the workplace:

I have 2 clients who have said that if they disclose that they have a mental illness when going for a job they would not have got the job.

(NGO Worker, New South Wales, Broken Hill Forum #21)

One client did eventually disclose her medical history three months after she got a job and then promptly lost that job.

(NGO Worker, New South Wales, Broken Hill Forum #21)

Where is the employment for our kids? Our children are being discriminated against by sophisticated means.

(Carer, New South Wales, Parramatta Forum #1)

Teacher, police officers etc would be very reluctant to tell their employers they have a mental health problem.

(Consumer, New South Wales, Broken Hill Forum #24)

Meanwhile sufferers continue to lose their jobs when employers discover they have an eating disorder ...

(Anonymous, New South Wales, Submission #58)

6.1.5 STANDARD 5: PRIVACY AND CONFIDENTIALITY

The MHS ensures the privacy and confidentiality of consumers and carers.

 Under this Standard, submissions and presentations indicate concerns about:

• lack of privacy and outdoor physical space;
• inadequate indoor physical care environment;
• staff applying privacy and confidentiality rule without authority or ignore or do not request permission from consumer to share information or involve carers;
• Indigenous issues;
• prisoners and problems with information sharing between agencies;
• information sharing with the police;
• privacy laws and assisting youth to access care; and
• rights of carers (carers not informed of discharge).

6.1.5.1 Lack of privacy and outdoor physical space

One consumer advocate expressed concern about the lack of private outdoor space in inpatient units. In particular, not only was this space described as being open to view by the public, but that it was unsafe in design (potential for suicide) and conveyed a sense to the consumers and to the public that mental illness equated to a criminal offence (20ft wire fences with a security guard). Standard 5.6 states: 'The location used for the delivery of mental health care provides an opportunity for sight and sound privacy' and Standard 5.7 states 'consumers have adequate space in regard to indoor and outdoor physical care environments'. Clearly though, as the following show, there are many problems with meeting this Standard:

I would like to talk about St Vincent's Hospital and the fence that surrounds that hospital. It's surrounded by a 20ft high wire fence! There's no privacy for consumers in the court yard or the ward. It is opposite a fashionable cafe where diners can view the inpatients clearly. The fence comes up and turns in at the top - not outward. It's a great place to hang oneself! There are also security guards sitting in the courtyard reading novels during the day. Compare this with Prof Pat McGorry's unit in Melbourne where they planted shrubs which have grown into hedges. It is a stark contrast.

(Consumer Advocate, New South Wales, Parramatta Forum #3)

There have been complaints made to St Vincent's but nothing has been done about it. I think it's there to stay. The nurses lobbied for it and said they had it built to protect their patients and themselves from people coming in off the street. I'm not opposed to secure units at all. That's not what I mean. What I mean is that we need to give more thought about how we build secure units. They shouldn't look like cheap prisons. People, even high security people have a right to privacy and respect.

(Consumer Advocate, New South Wales, Parramatta Forum #3)

6.1.5.2 Inadequate indoor physical care environment

Concern was also expressed about the poor standard of hygiene, cleanliness and ambience of inpatient units. Even though Standard 5.7 states that consumers should 'have adequate space in regard to indoor and outdoor physical care environments' it appears the reality for many consumers was far from this:

During December 2001 and January 2002, we observed that both the MHU wards (open and lock-up) were generally in a filthy state, and we saw numerous cockroaches everywhere. It was embarrassing, in fact, when we met with our daughter's clinical psychologist in the MHU lock-up ward and we all observed cockroaches on the wall; we turned blind eyes because they were the least of our worries. But, we ask, how can a hospital environment permit this? And what does it say about the professionalism of the ward management and staff, and their concern for patients?

(Carers, Parents, New South Wales, Submission #106)

Mental health services in this state, this city are shabby, dirty places. The walls have no posters or adornment. I really can't see the point of someone with a mental illness coming into an environment like that.

(Consumer Advocate, New South Wales, Parramatta Forum #3)

...we have lost our son in Carasta [Caritas] Mental Health Hospital (Branch of St Vincent Hospital Sydney) ... They knew he was very sad, but when we saw the hospital where it happened it was so depressing. They told us that depressed people did not notice their surroundings.

(Carer, Mother, New South Wales, Submission #135)

The James Fletcher Hospital is also frequently "dirty" ... cleanliness could be upgraded to hospital standard. For example, the carpets are very dirty, which leaves patients with black feet. There was an example of food smeared on a window which was left for more than 3 weeks. A dead cockroach was left lying in a corridor for several days. There are frequently coffee stains left on the garden furniture. Overall, it is a very dirty environment, not what you would expect from a hospital. There is also no air-conditioning or fans and so no fresh air. The fans were removed after a patient attempted to hang themself. A plan for installation of air conditioning was developed 12 months ago, but no action has occurred yet. Furthermore, there is only one meal option available to patients, regardless of the individual's tastes or beliefs. There is often no privacy for patients using the telephone because if there is a staff meeting being held in the room housing the phone it is placed in the hallway ... patients are treated as 2nd class citizens. They do not receive the same level of care you would receive in other health facilities.

(Anonymous, New South Wales, Submission #156)

6.1.5.3 Staff applying privacy and confidentiality rule without authority or ignore or do not request permission from consumer to share information or involve carers

Both clinicians and carers expressed concerns that a misunderstanding of the Privacy Act and related policies and procedures to protect the confidentiality and privacy of consumers is hampering communication between consumers, carers and clinicians in the provision of treatment and the sharing of vital information. Furthermore, these concerns would suggest that these policies and procedures are not always being made available to consumers and carers in an understandable language and format (Standard 5.2) and that the mental health system is not encouraging and providing opportunities for consumers to involve others in their care (Standard 5.3):

One of my biggest gripes was the privacy law and how I as [X]'s wife was not told anything that could benefit him or myself. ([X] completed suicide 7 days after discharge)

(Carer, Wife, New South Wales, Submission #126)

We have received complaints that people close to a patient have been told by staff that the person has objected to notice and other information being given out and the patient has stated that they made no such objection. This is abuse of the law which could be guarded against by our suggested Advance Directives, admission procedures and creation of a information consent Form, but really it ought not occur for reasons of right conduct.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

...the laws are often given as an easy way to avoid talking about issues with people involved with the patient regardless of the appropriateness or otherwise of the request, and c) privacy laws are often attacked because they are inaccurately blamed for lack of social support, and general medical information about psychiatric disability comprehensible to the general public that people close to a patient might need ... Generally, no matter what laws are enacted regarding them, the problems of information/privacy issues will always come down to the attitudes of all parties in the practical application of any such laws. These are complex relationship and social issues that have to be dealt with at the grass roots level and though three way learning between professionals, patients and people connected to patients.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

Having made these points we wish to state that we believe that legislatively and in practice, that there are problems with the definition and interpretation of classes of persons that are allowed to have/give information.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

No other class of people has their personal individual innermost thoughts so examined by others as psychiatric patients. Inspected, rejected, accepted, labelled, classified, dismissed, pathologised. Judged. It is crucial that they have some space to exist in as a person, and are accorded rights not to have their experience and thoughts blathered to all and sundry. That is a fundamental and profound issue of rights that can directly affect the survival of the person. It needs to be upheld for that reason, regardless of the fact that it is also 'therapeutic' and 'in accordance with privacy laws'. Patients must be informed of any disclosure to another party. They have a right to know what is happening with their information, and to whom it is given. To not abide by this principle is to create a situation of secrecy and actions carried out in an underhand manner.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

We contend that the maintenance of privacy of information must be upheld, and that the laws regarding information in no way accord too many rights to the patient as has been suggested. We oppose any degradation of rights of patients in regards to their information and privacy, and we contend that in many areas it needs to be strengthened. We support provision for discussion and mechanisms that allow for diverse relationships to be recognised and for information to be shared in non-abusive ways.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

It should never be assumed that the person is incapable of considering a matter, forming an opinion and giving direction regarding the matter. This includes who is privy to information and who may be involved in admission, treatment, and discharge, in terms of Health and non-Health persons and the interaction of the two. There is generally a presumption that any patient with psychiatric disability lacks capacity. This is untrue.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

I do not think that being over the age of 18 should stop doctors from letting families know more of their loved ones feelings so that they can understand.

(Carer, Mother, New South Wales, Submission #88)

One carer expressed concern that although the mental health system provides opportunities for consumers 'to involve others in their care' misunderstandings of laws and policies in relation to privacy and confidentiality are hindering carers from accessing care on behalf of the consumer when needed:

For a number of years, I have been trying to access mental health services for my daughter, who is now approaching 17 ... Throughout the last year, her mental state has deteriorated badly and I am no longer able to seek help for her because her age precludes it.

(Carer, Mother, New South Wales, Submission #92)

6.1.5.4 Indigenous Issues

The Indigenous Social Justice Association (ISJA) and Justice Action (JA) expressed concern that issues related to privacy and confidentiality for Indigenous people must also be addressed within a cultural context (and therefore related to Standard 7 - Cultural Awareness):

It is a necessity to recognise formally the Indigenous concepts of family, kinship and community, and to allow communities and individuals within the Indigenous communities to work out appropriate ways of dealing with information that affects the relationships within the Indigenous communities. Indigenous Cultures must be respected and Indigenous people must not be forced or pressured to reveal Cultural information. There are arrangements already existing that are supposed to be respected, such as the AHRC / NSW Health Partnership, to look into these issues and ensure that matters affecting Indigenous people(s) are dealt with at all law, policy and service levels in the appropriate and culturally respectful manner. It cannot be allowed to be done in ignorance of the rights and concerns of Indigenous peoples and without self determination. As these issues are already known to government and departments, a choice to ignore the issue and deny rights amounts to a deliberate decision which we contend must be examined with regard to the International Convention on Genocide. We also argue that these issues be examined in the light of the 2003 WHO guidelines on Mental Health Law and Human Rights regarding the protection of Indigenous ethnic groups and minorities.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

6.1.5.5 Prisoners and problems with information sharing between agencies

The Indigenous Social Justice Association (ISJA) and Justice Action (JA) also expressed concern about the right to privacy of prisoners with mental illness and how their privacy has not been respected and consumers have not given 'informed consent before their personal information is communicated to health professionals outside the MHS, to carers or other agencies or people' (Standard 5.4):

We wish to express here our absolute objection that prisoners, as an entire class of people, have by law no right to privacy due to recently passed laws. This discrimination is offensive in and of itself. It is also highly damaging to prisoners' wellbeing and relationships with medical staff and others. Prisoners' patient records have been given to the media, for example the X-rays of the hand of Ivan Milat. (We note that forensic patients' mental state and therapeutic relationship has also been released and discussed in the media, and that this is a nation-wide problem. Forensicare of Victoria is often considered exemplary in debates around forensic standards, but they are in no way immune from problems and have also revealed such personal information in an inappropriate and political manner.)

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

We have received complaints directly from prisoners so affected about the new lack of privacy laws in NSW. We demand that the laws be repealed, and that prisoners be granted rights of medical privacy in accordance with other patients. Corrections should under no circumstances have the right to give out such information and Corrections is not the prisoner's 'carer'.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

We have also described general privacy problems regarding medical treatment in jail and demand that prisoners seeking medical treatment be accorded respect and that their medical rights as a human being be upheld. Prisoners must also be able to nominate friends/family/advocates as per below and have access to their information and control over who is allowed to have it like any other person.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

We also completely object to NGO / Police access to databases and information sharing regarding the mental state and medical records of patients as suggested in submissions and hearings at the NSW Parliamentary Inquiry into Mental Health Services. This is an abuse of patient's private information and must not occur. NGO's and Police can contact Mental Health Teams if really necessary.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales, Submission #349)

6.1.5.6 Information sharing with the police

Concern was expressed by the police that due to the inability of consumers to access mental health services when required and increasing reliance by families and the community on the police to intervene and assist, that the police should have access to data about consumers in order to provide more appropriate responses. As mentioned above, Standard 5.4 states: 'Consumers give informed consent before their personal information is communicated to health professionals outside the MHS, to carers or other agencies or people'. While information may need to be shared in specific circumstances, in order to meet this Standard, and protect many rights of consumers beyond confidentiality, the appropriate response would be to first improve the response by the mental health service to minimise the need for police involvement on such a large scale:

Funding needs also to be provided for the establishment of a national health system for the identification purposes in relation to the medical history of those persons with mental illness or disorders with ready access to police to assist them in their encounters with these individuals.

(Police Association of New South Wales, New South Wales, Submission #59)

There needs to be a greater sharing of information by the health department to police in relation to a mental health issues. This could possibly take the form of a type of national database which could contain records of names of individuals who have been hospitalized, the types of mental illness they suffer etc so that when police come in contact with the individual, through the hospital they can be accurately informed as to their mental state, which would be of great assistance in helping police determine how they could be best treated.

(Police Association of New South Wales, New South Wales, Submission #59)

6.1.5.7 Rights of carers - carers not informed

One carer expressed her frustration that carers of consumers also have the right to information that impacts on them, and that it should not just be consumers who claim the right to withhold information:

I have four children and 3 with a serious mental illness. I want to outline an issue about the rights - the human rights of carers. My daughter was taken into care involuntarily - taken in as an involuntary patient and we weren't informed. I didn't know for 24 hours where my daughter was - I knew she was acutely ill but not where she was. When I approached the hospital they informed me that my daughter has exercised her right not to inform her family.

(Carer, New South Wales, Sydney Forum #9)

6.1.6 STANDARD 6: PREVENTION AND MENTAL HEALTH PROMOTION

The MHS works with the defined community in prevention, early detection, early intervention and mental health promotion.

 On 4 December 2001, my wife discussed our daughter's condition with her treating psychiatrist, the MHU Psychiatric Registrar and MHU nursing staff, who agreed that the MHU did not cater for our daughter's then current mental state - she was not psychotic. At the request of my wife, and our daughter's clinical psychologist, our daughter was placed in the MHU lock-up ward for her physical protection. It was not until four weeks later, when our daughter's condition had significantly deteriorated, that she was "specialled". We later discovered by accident that "specialling" is normal procedure for vulnerable patients. It seems reasonable that early "specialling" for our daughter would have significantly reduced the severity, duration and cost of her confinement and prevented her ongoing loss of hair and teeth problems from unnecessary malnutrition.

(Carers , Parents, New South Wales , Submission #106)

Under this Standard, submissions and presentations indicated concerns about:

• a lack of focus on early intervention or prevention programs;
• unfairness of promoting early intervention when services are failing to cope with current demand;
• need for more programs to promote mental health and prevent mental disorders in the deaf community;
• need for more programs to promote mental health and early intervention to people from a non-English speaking background;
• preventing depression in older men; and
• substance abuse and mental illness need to be tackled jointly in mental health promotion programs with children and youth.

A sense of disbelief at how government funding was allocated was conveyed by many. This is aptly captured in the following quote:

I think it's terrible that the NSW Government can spend $1.2 million to put up a suicide barrier on a bridge but can't put money into improving access to mental health care.

(Consumer, New South Wales , Sydney Forum #4)

6.1.6.1 A lack of focus on early intervention or prevention programs

Standard 6.8 states: 'The MHS ensures that the consumer has access to rehabilitation programs which aim to minimise psychiatric disability and prevent relapse'. Concern was expressed however that the mental health system places little emphasis on rehabilitation programs or other programs to prevent relapse or promote recovery and instead waits for a crisis to occur before responding:

I work in a psychosocial rehabilitation unit. I think it's unbelievable that things haven't changed. I have met some very dedicated people in the hospital system but I've also seen the opposite. It all starts with the under-funding of services and this undervalues the problem. People are called the 'worried well' and turned away until they are in crisis. The system is structured in such a way that there's too much of a reliance on medication and not enough attention to the other important things like rehabilitation and psychosocial support, housing, etc.

(Mental Health Worker, New South Wales, Sydney Forum #10)

We require more support groups for people experiencing depression anxiety. There is no money going into programs that promote or enhance recovery.

(NGO worker, New South Wales, Sydney Forum # 8)

[There are] no early intervention programs

(Consumer and Consumer Advocate, New South Wales, Submission #169)

We support a population health model, with its emphasis on promotion, prevention and early intervention in mental health. Many of our organisations believe that the Eastern Suburbs Mental Health Program is falling far short of achieving systematic and strategic approaches to early intervention, often failing to respond effectively or provide any service at all, on many occasions when consumers in our services are in need of proper assessment and timely intervention ... We request the implementation of National Standards as they relate to early intervention and continuity of care.

(Eastern Area Interagency NSW, New South Wales, Submission #100)

Closure of the Living Skills Centres has not been accompanied by any coherent implementation of Statewide, recovery-focused rehabilitation services.

(SANE Australia, National, Submission #302)

6.1.6.2 Unfair to promote early intervention when services are failing to cope with current demand

Although the policy shift to prevention and increasing community awareness of available interventions is laudable, an unforeseen consequence for existing services is the generation of more referrals in addition to providing services to "core" patients in high risk groups.

(Public Sector Psychiatrists, New South Wales, Submission #297)

Clinicians expressed concern that there are insufficient services, resources and committed funding to respond to increasing access demands as a result of mental health promotion programs. Clinicians stated that adequate funding and the structure of service delivery needs to be addressed to cope with current and increased future demand to intervene at the earliest possible moment. Standard 6.1 states: 'The MHS has policy, resources and plans that support mental health promotion, prevention of mental disorders and mental health problems, early detection and intervention'.

This means that as there is no follow up people return to their previous bad state and so these clients have to repeat the whole the process.

(NGO Worker, New South Wales, Broken Hill Forum #5)

The prevention 'push' often has encouraged the funding of short-term projects that risk increasing expectations without interventions being sustainable. Such funding enhancements generally have not generated ongoing new mental health services. In addition, other effective sources for referral have diminished. GPs are often too busy and funding constraints limit the availability of the private sector.

(Public Sector Psychiatrists, New South Wales, Submission #297)

Need to educate the community so they recognise the symptoms.

(Clinician, New South Wales, Broken Hill Forum #25)

6.1.6.3 Need for more programs to promote mental health and prevent mental disorders in the deaf community

As mentioned above, access to interpreters for people with hearing impairment is difficult and not all promotional strategies would successfully reach this community. Standard 6.4 states: 'The MHS has the capacity to identify and appropriately respond to the most vulnerable consumers and carers in the defined community'. Also Standard 6.2 states: 'The MHS works collaboratively with health promotion units and other organisations to conduct and mange activities which promote mental health and prevent the onset of mental disorders and/or mental health problems across the lifespan'. One community worker expressed concern that insufficient programs, strategies or funding are available to prevent mental disorders and psychiatric disability in the deaf community, particularly amongst the young:

The rate of young deaf people suiciding is very high. There's no funding to even enable us to print out emergency deaf cards. We would like the government to help us but it won't ... it doesn't.

(Disability Community Worker, New South Wales, Parramatta Forum #2)

6.1.6.4 Need for more programs to promote mental health and early intervention to people from a non-English speaking background

Standard 6.3 states: 'The MHS provides information to mainstream workers and the defined community about mental disorders and mental health problems as well as information about factors that prevent mental disorders and/or mental health problems'. Included in the notes to this Standard are 'local community groups'. Given the cultural diversity of NSW this would include culturally and linguistically diverse communities. For these communities, many barriers present as a problem when discussing prevention and mental health promotion strategies including literacy skills in English and other languages spoken at home, knowledge of the health system and cultural barriers to acknowledging disability and accessing care. Concerns were expressed that insufficient support services and resources have been allocated to assist consumers from a non-English speaking background and refugees to recognise symptoms and access services as early as possible:

We have to continue to invest in this area. The messages need to be multi-level, and multi media - not just brochures. It takes a fair bit of resources and time. The short term funding that we get to develop and provide resources and supportive programs is a problem, we need long term funding so that we can have a meaningful impact.

(Mental Health Promotion Worker, New South Wales, NESB Parramatta Forum #11)

People in the NESB communities don't understand the system of mental healthcare. So they don't know what is available. They need to use NESB workers but these positions are disappearing, particularly difficult to find a worker who is fluent in the right language for the client. So for example, Polish people are assisting people from Arab backgrounds etc. Ethnic health workers are filling the gaps but these people have different skills and are not as appropriate as multicultural health workers. The rigid funding barriers make it worse.

(Multicultural Mental Health Worker, New South Wales, NESB Parramatta Forum #6)

We provide settlement services and aged care services for the Polish Community. The biggest issue/problem facing this community is mental health problems. The refugees in the 40-50 age group have a high level of post-war trauma that has not previously been dealt with properly. There's also a lot of people with dementia and other mental health issues and people presenting with personality disorders. These people have had these illnesses and been untreated for a very long time. They have developed survival techniques but they can't go on like that. They need help and support but it's not available.

(NESB Welfare Worker, New South Wales, NESB Parramatta Forum #2)

An off shoot of Temporary Protection Visa is long-term mental illness and stress. And family isolation contributes to mental illness.

(Anonymous, New South Wales, NESB Parramatta Forum #1)

6.1.6.5 Preventing depression in older men

Men need more support - because they don't ask for help. There's nothing in this town for men - no support. My partner phoned his parole officer to ask for help because there was nothing else for him.

(Consumer, Female, New South Wales, Broken Hill Forum #24)

Standard 6.5 states: 'The MHS has the capacity to identify and respond to people with mental disorders and/or mental health problems as early as possible'. However, the inequity of treatment and early access to services for different population and age groups was a key concern for some. For example, concerns were raised that the needs of older men who are at increased risk of developing depression were not being met by the mental health system:

A final point to be noted is that although a lot of money has gone into prevention of suicide among young people in Australia, there has been comparatively little attention to the continuing high suicide rate among men in late old age... we need to examine how best to help those whose depression is closely linked to painful or disabling physical illnesses.

(Clinician, New South Wales, Submission #264)

Broken Hill has got the highest suicide rate of older men in NSW. Morbidity is highest in New South Wales' far west. Broken Hill has an ageing population. There is a demographic shift in Broken Hill which means there is an increasing older population and decreasing younger population as many move away to seek higher education and build there lives in other places where they can find work and hope. We need more mental health first aid - looks like it empowers you. We need to educate the community so they recognise the symptoms.

(Clinician, New South Wales, Broken Hill Forum #25)

6.1.6.6 Prevention - substance abuse and mental illness need to be tackled jointly

Concerns were expressed regarding the need to address substance abuse and mental health problems jointly. This indicates greater attention to a preventive focus in the delivery of mental health services is required, as outlined by Standards 6.4 (capacity to identify and respond to the most vulnerable consumers n the community), 6.5 (capacity to identify and respond as early as possible) and 6.6 (treatment and support to occur in a community setting in preference to an institutional setting).

Given the known consequences of substance abuse, it is alarming that treatment and support services are not provided at the earliest possible moment to prevent deteriorating illness. Result of this failure can include deteriorating physical and mental health, risk of harm to self or others, unemployment and social withdrawal, and the need for acute care in restrictive settings with severe treatment regimes.

Excellent prevention strategies are in place in regard to tobacco smoking saving many lives and millions of dollars from the health budget. We need similar public health education and awareness campaigns in relation to marijuana abuse. For example a teenager who has a joint every weekend at a party (smokes cannabis 50 times or more before 18 years) has the following increased risk of serious harm: 6.7 times greater risk of developing schizophrenia (Andreasson et al. 1987; Zammit et al. 2002); 59 times greater risk of using other illicit drugs; Increased risk of depression and suicide; Greater risk of cancer cigarette for cigarette than tobacco cigarettes (50% greater tar burden)

(Clinician, New South Wales, Submission #181)

Lack of information was noted as a major problem for young people receiving care in the hospital system. Young people reported that the primary treatment offered was medication but were concerned about dependency and the lack of monitoring and aftercare by treating staff. Young people stressed that youth services and telephone counselling services were supportive but some young people did not know about them until too late.

(NSW Association for Adolescent Health, New South Wales, Submission #98)

Most participants reported taking drugs at early ages (12-14 years) and experiencing psychotic episodes some years later. Commonly, they did not seek help or recognise that they needed help. They reported having a vague understanding of what schizophrenia is but they failed to associate their own experiences with such a mental illness. In most cases, the first episode of their mental illness was diagnosed when they were brought into hospital by police and assessed and hospitalised in the psychiatric ward.

(NSW Association for Adolescent Health, New South Wales, Submission #98)

6.1.7 STANDARD 7: CULTURAL AWARENESS

The MHS delivers non-discriminatory treatment and support which are sensitive to the social and cultural values of the consumer and the consumer's family and community.

People who do not speak English as their first language have very limited access and their linguistic and cultural needs are not met.

(NESB Consumer Advocate, New South Wales , Parramatta Forum #8)

Under this Standard, submissions and presentations indicated concerns about:

• lack of culturally appropriate practices for consumers from a non-English speaking background;
• problems with treatment due to cultural barriers and intellectual disability;
• the need for cultural competency training of staff in the MHS; and
• utilisation of staff and services with expertise to provide services to consumers from a NESB.

6.1.7.1 Lack of culturally appropriate practices for consumers from a non-English speaking background

Comments were received which suggests that mental health services have not been planned and delivered in a manner which 'considers the needs and unique factors of social and cultural groups represented in the defined community and involves these groups in the planning and implementation of services' (Standard 7.2). Concern was expressed that in many instances staff were not accommodating the cultural need of consumers to have family present during assessment. Also, concern was expressed that even though culturally appropriate practices could be enhanced by employing staff from a variety of backgrounds, sufficient resources were not available to enable this to occur:

When our clients are assessed, the families want to be included but most of our staff are Australian. So language barriers are a problem. Staff are paid poorly so we take whoever we can get.

(NGO Service Provider, New South Wales, NESB Parramatta Forum #10)

Outcome based interventions don't necessarily work for CALD groups. We need to be able to be flexible with the delivery of interventions to NESB communities and tailor programs to the individual.

(Anonymous, New South Wales, NESB Parramatta Forum #16)

Concern was also expressed that staff of the mental health service may not have the requisite 'understanding of the social and historical factors' relevant to the current circumstances of social and cultural groups represented in the defined community (Standard 7.1):

We have people who are victims of concentration camp medical experiments. She was admitted to hospital but had PTSD [Posttraumatic Stress Disorder].

(NESB Welfare Worker, New South Wales, NESB Parramatta Forum #2)

6.1.7.2 Problems with treatment due to cultural barriers and intellectual disability

One consumer advocate expressed concern regarding the management of a person from a non-English speaking background with intellectual disability. It seems that many factors contributed to the infringement of this person's rights including: interpreter not involved; advocate or support person not involved; consumer or carer not being made aware of their rights and access to interpreters and advocates and information; staff social and cultural prejudice; and lack of disability awareness by staff:

There was a lady from Bosnia, a refugee, who has an intellectual disability. Because of her inappropriate assessment she was involuntarily admitted to hospital for a mental illness. She was considered to have PTSD but she didn't. Some people with an intellectual disability do have behavioural problems but not like a mental illness. I applied under the FOI [Freedom of Information] Act to get access to files to lodge a complaint - we have been waiting for two months and haven't received any medical files. The mother recently suffered a stroke her sister is caring for her.

(NESB Consumer Advocate, New South Wales, Parramatta Forum #8)

6.1.7.3 Need for cultural competency training

Standard 7.5 states: 'The MHS monitors and addresses issues associated with social and cultural prejudice in regard to its own staff'. Included in the notes to this Standard are 'cross cultural training for staff' and 'carers from a range of different social and cultural groups'. However, evidence presented suggested that in some cases this was not happening. It was suggested that staff of mental health services are in need of cultural competency training that will assist them to modify their attitudes and behaviours (decrease discrimination) when dealing with consumers from a non-English speaking background:

Cultural competence doesn't exist at the level it's needed. No cultural competence taught. Unless we make it as a core competency, it won't happen.

(New South Wales, NESB Parramatta Forum #14)

Multicultural courses are available but they are predominantly short courses and they are not mandatory. And these courses are often attended by the converted!

(Anonymous, New South Wales, NESB Parramatta Forum #15)

Staff development is really failing at a systematic level to deliver outcomes for people from a NESB. What do we need to do to improve the cultural competencies of the workers? We are seeing increasing institutional racism.

(NESB Consumer Advocate, New South Wales, NESB Parramatta Forum #7)

There is really inadequate training for consumer issues related to settlement.

(NESB Consumer Advocate, New South Wales, Parramatta Forum #8)

6.1.7.4 Utilisation of staff and services with expertise to provide services to consumers from a NESB

Standard 7.4 states: 'The MHS employs staff or develops links with other service providers/organisations with relevant experience in the provision of treatment and support to the specific social and cultural groups represented in the defined community'. Concerns were expressed from consumers, advocates, multicultural mental health workers, NGO service providers and clinicians that a sufficient number of skilled staff are not being employed to meet demands. Consequently, systemic problems exist with the operation of current policies and the interface between specialist and mainstream services for consumers from a NESB:

There's a systemic failing on a policy level and a marked reduction of providing multicultural workers because we are being mainstreamed.

(NESB Consumer Advocate, New South Wales, NESB Parramatta Forum #7)

I am 1 of 30 bilingual counsellors for NSW. We are not psychiatrists however we do feel the brunt of the community's need. I am aware of only one Spanish speaking psychiatrist. We need a review of bi-lingual psychiatrists.

(Multicultural Mental Health Worker, New South Wales, NESB Parramatta Forum #8)

There's no balance between the ethno-specific workers and mainstream workers.

(NGO Service Provider, New South Wales, NESB Parramatta Forum #10)

Pilots and one-off grants make it very difficult for us to reach out to the communities. Mostly now we don't apply for this money. It's not fair to build people's expectation.

(Clinician, Rehabilitation, New South Wales, NESB Parramatta Forum #17)

6.1.8 STANDARD 8: INTEGRATION

6.1.8.1 Service Integration

The MHS is integrated and coordinated to provide a balanced mix of services which ensure continuity of care for the consumer.

 Under this Standard, submissions and presentations indicate concerns about:

• lack of coordinated care in rural and regional areas due to high staff turnover;
• chronic under-resourcing resulting in inability of MHS to deliver integrated and coordinated care;
• inability of MHS to deliver coordinated and integrated services to consumers from a non-English speaking background;
• links with NGO services;
• inability of mental health teams to provide services resulting in reliance on police force; and
• problems with Schedule II procedures and integrated and coordinated care.

6.8.1.1.1 Lack of coordinated care in rural and regional areas due to high staff turnover

According to Standard 8.1.4: 'Opportunity exists for the rotation of staff between settings and programs within the MHS, and which maintains continuity of care for the consumer'. Also Standard 8.1.1 states: 'There is an integrated MHS available to serve each defined community'. Reports of high staff turnover also concerned consumers in one regional area as this meant that consumers were not receiving continuous care:

There's no continuity of care or no time to establish relationships as staff move on very quickly in this area.

(Consumer, New South Wales, Broken Hill Forum #2)

With resident specialists so often on leave or moving on it is hard to have to re-tell your story to each new arrival. People with mental illness need to build relationships and trust. We can't do that here because we lose staff quickly.

(Consumer, New South Wales, Broken Hill Forum #2)

6.8.1.1.2 Chronic under-resourcing resulting in inability of MHS to deliver integrated and coordinated care

Concerns were also expressed with regard to the shortage of clinical staff in the sector to provide the required treatment and support when consumers were trying to access services or when clinicians were referring consumers for treatment. The shortage of psychologists and psychiatrists in the public sector was reported, as was the shortage of general practitioners who bulk-bill and who have adequate mental health training:

We need a link for people to refer to so people can access care. As there is very limited access to psychiatrists and long delays in seeing psychiatrists, it means many people have to return to GPs to try and get help. But access to GPs is not always easy given the decline in bulk billing.

(Family Support Services Worker, New South Wales, Broken Hill Forum #12)

There is a focus on clients presenting for the first time, at the expense of long-term clients. [X] believes this philosophy of the mental health services "means to me they have given up on the long term patients".

(Anonymous, New South Wales, Submission #156)

A person needs to be on the "acute board" to get a home visit from the mental health team. People at the acute stage of their illness are registered on an awareness / priority register for mental health nurses. Only the hospital doctor at the hospital can put a person on the board.

(Anonymous, New South Wales, Submission #156)

[X] went to a psychologist just 2 months before he died - who referred [X] to a psychiatrist - but unfortunately the psychiatrist was away on holidays - so he couldn't get an appointment - in the detailed referral it was obvious to blind Harry that [X] was screaming out for help he had in a one hour session with the psychologist relayed every vital piece of information in regard to his condition. [X] should never have been allowed to leave that psychologist's office - in the referral it said he had a (suicide) plan - it wasn't the first time etc etc.

(Carer, Mother, New South Wales, Submission #122)

Even this last hospital admission, with a CTO order in place took ridiculous co-ordination between Community Health Centres to ensure that Mum could get picked up. Mum had to be breached, the breached approved, approved to be faxed to the other centres, and then maybe she could be picked up. Meanwhile, you are starting to get nervous as your mother takes to the streets more, her mental health and hygiene slowly deteriorating. Trust me when I say that the catch me if you can game can take weeks, even months.

(Carer, Daughter, New South Wales, Submission #134)

Mental health services are shifting clients onto GPs. However, whilst GPs have now received some training in mental health, they don't have sufficient time to give to patients for mental health consultations. They also have limited training. For example, the GP for [X]'s wife is not fully up-to-date on medications.

(Anonymous, New South Wales, Submission #156)

I have had Schizophrenia since 1976 ... I go regularly to see a psychiatrist at Prince of Wales Hospital. Though there's now only 1 psychiatrist left out of the 8 that were there when I first started going years ago. 1 psychiatrist is hardly enough is it?

(Consumer, New South Wales, Sydney Forum #4)

[X] was identified by a psychologist as suicidal and referred to his doctor [GP]. After repeated attempts to get an appointment, he saw his doctor. Before the appointment occurred he attempted suicide. After keeping his doctors appointment which was only a half hour after the attempt, I was summonsed to drive him to the Emergency Section of our hospital. [X] was given a letter by his doctor in which the doctor stated that the Psychologist [X] had seen on the previous Monday had informed him that he thought [X] was suicidal. Yet, at NO time did [X]'s doctor call him as a matter of urgency to go and see him or to offer help in any way. Lack of duty of care as far as I'm concerned.

(Carer, Wife, New South Wales, Submission #126)

Mental Health staff report they do not have the resources and staff required to meet the demand for mental health services, and services in areas such as supported accommodation, outreach, self-help and rehabilitation are wholly inadequate. Mental health teams no longer provide long-term case management and are limited instead to 'episodic care', with short-term interventions followed by the referral of chronic mental health clients to general practitioners (GPs) for case management. Even so, mental health teams are struggling with caseload pressures.

(NCOSS, New South Wales, Submission #47)

MATT (mobile assertive treatment team) - work with severely sick psychotic people to keep them out of hospital - only one team with 7 staff who see 70 clients for the Central Sydney area which has 5000 consumers, 500 of whom would benefit from seeing the MATT team, which provides intensive case management, support, counselling and supervision

(Consumer and Consumer Advocate, New South Wales, Submission #169)

Case managers in the Community Health Centres are overloaded - have to manage too many consumers (30 each? e.g. 28 people for 1 day a week) - not enough time to work intensively with people. There is hardly any money for community treatment. Crisis teams do not have enough time to spend with consumers in crisis - only time to quickly check symptoms and medication, no time for counselling

(Consumer and Consumer Advocate, New South Wales, Submission #169)

Concern was also expressed regarding staff leaving without planning for continuity of care. The impact for one consumer of having to restart the care process without notification or transition time was devastating. Standard 8.1.4 states: 'Opportunity exists for the rotation of staff between settings and programs within the MHS, and which maintains continuity of care for the consumer'.

A few years ago she finally found a great doctor she trusted. Dr [Z] worked in a Western Sydney Hospital, and for a couple of years she was stable and quite normal, until one day she turned up to her appointed only to be told he had moved to America. EVER SINCE THIS DAY, we have been battling to keep her stable. This doctor had not arranged a transition time to a new line of help. He just left and did not care about the consequences. (author's emphasis)

(Carer, Sister, New South Wales, Submission #79)

6.1.8.1.3 Inability of MHS to deliver coordinated and integrated services to consumers from a non-English speaking background

Standard 8.1.1 states: 'There is an integrated MHS available to serve each defined community' and Standard 8.1.5 states 'the MHS has documented policies and procedures which are used to promote continuity of care across programs, sites, other services and lifespan'. As previously mentioned, many concerns were expressed about the ability of the mental health system to deliver coordinated treatment and care to consumers from a non-English speaking background as reported in the following quotes:

The bilingual counsellors do take the brunt. I am coming across this over and over again. We can do an assessment and see people for 6 sessions then we have to refer them on to mainstream services but they bounce back to us.

(Multicultural Mental Health Worker, New South Wales, NESB Parramatta Forum #9)

I was part of a major service re-educating GPs and developing shared care etc for NESB. It's taken about 5 years and there is evidence that it's working. Everyone puts in an effort but it's just not enough to help someone like me from an acute mental health service dealing with someone from Somalia for example.

(Mental Health Worker, New South Wales, NESB Parramatta Forum #12)

6.1.8.1.4 Breakdown in Links with NGO services

One clinician from an NGO service expressed concern about the lack of resources and breakdown between NGO service providers and the mental health service and not being able to work together to provide continuity of care in a coordinated and integrated manner as stated in Standard 8.1.5:

There's a real breakdown between NGO & public services. The Government is happy to treat NGO's as extensions of services but not fund them accordingly. In fact the Government has cut funding to NGOs and still expects that the NGO's will carry the load. I have had to put a ban on all referrals from services. We're now in a position where we are rationalising our services. We don't like it but we have to run our service within the resources we have to work with ... My service has a budget of $400,000 / year but our funding hasn't increased since early 1990s.

(NGO Clinician, New South Wales, Sydney Forum #3)

6.1.8.1.5 Inability of mental health teams to provide services resulting in reliance on police force

Standard 8.1.1 states: 'There is an integrated MHS available to serve each defined community', including case management and crisis intervention. The under-resourcing of community based services led one consumer advocate and the Police Association of NSW to express concerns that coordinated care was not being provided and, as a result, police were required to become involved unnecessarily:

The community staff are stretched to the maximum and their resort is to tell people to go to their GP or access an emergency service (was one very recent answering machine message I happen to hear when I was trying to contact a community health worker. Mind you, no information about how to contact the emergency service was part of the message.)

(Consumer and Consumer Advocate, New South Wales, Submission #8)

Even though they claim to be available 24 hrs a day / 7 days a week through a 1800 telephone number, they are not providing a true 24/7 service ... Currently, police are finding themselves being called prematurely and often unnecessarily to assist in the management of patients who have been released into the community or who are allegedly being treated while living in the community. They are also often being asked to retrieve AWL (Absent Without Leave) patients from the community without any attempt of the mental health teams to bring the patients back to hospital using their own resources ...

(Police Association of New South Wales, New South Wales, Submission #59)

6.1.8.1.6 Problems with Schedule II procedures and integrated and coordinated care

The Police Asso