Mental health system is broken and beyond a crisis, but solutions are at hand
Australia’s broken mental health system has failed hundreds of thousands of people with severe illness with ineffective care – and that’s if they can access any at all. But one initiative may shift the dial.
Australia’s broken mental health system has failed hundreds of thousands of people with severe illness who are receiving ineffective care, if they can access any at all, groundbreaking new analysis has revealed.
The nation’s hospitals have fewer than half the psychiatric inpatient beds needed, a joint investigation by The Australian and the Australian National University has discovered, and billions of taxpayer dollars are being wasted through the failure to provide secure housing to those with complex needs.
The decades-long neglect of those with chronic severe mental conditions has reached its worst point, with staff despair at such critical levels that both public and private hospitals are unable to fill psychiatry positions; the nation’s prisons overflow with those with mental illness; and GPs buckle under the weight of inadequate resourcing to care for patients with complex needs.
Patients, carers and public and private health systems are on the brink as the nation’s first comprehensive economic analysis of the extent of the unmet need in severe mental illness across frontline healthcare, social supports and housing, reveals a vast tide of suffering at a huge cost to the nation, leaving families as victims in its wake with devastating ripple effects on millions of Australians.
The analysis by the Australian National University, in partnership with The Australian, focuses on the estimated 2 per cent of adult Australians living with chronic severe mental health conditions.
A policy report to be released next week has found the shortfall in the provision of healthcare, social services and housing for sufferers amounts to about $8bn a year. Governments spend about $11bn a year on mental health-related services. But there is enormous potential to reap massive savings and vastly improve people’s quality of life, in particular through the provision of secure housing, which would slash spending on often ineffective care that would no longer be needed.
The report is entitled “Don’t Walk By: Unmet Need in Chronic Severe Mental Health Conditions”. Its lead authors are professor of medicine and health economist Steve Robson, who is also a medical columnist for The Australian’s Health & Wellbeing section, and Associate Professor Jeffrey Looi, a psychiatrist and the head of the ANU’s Academic Unit of Psychiatry and Addiction Medicine. The report says a crisis of neglect in the provision of care to the severely mentally ill, which largely traced back to the closure of asylums and the subsequent failure to fill the gap with community supports, could no longer be ignored.
“Australia has comprehensively failed a generation of people with severe mental health conditions,” Professor Robson said. “Many have no home, no help, no hope.”
Huge numbers of patients are locked out of accessing psychiatry and primary care. The economic and policy analysis, bolstered by empirical reporting by The Australian with devastated families, shows some of the most vulnerable people in the country are routinely relegated to homelessness or exploitation in squalid boarding houses, with ageing carers who fear for the future of their dependent adult children struggling to cope.
As well as the critical lack of supported housing, the mass exit of staff and the national shortfall of beds, The Australian’s week-long series will reveal:
• Suicide rates of the severely mentally ill are much higher than previously understood or documented.
• The nation’s health system has failed to provide comprehensive healthcare and integrated substance abuse services for the severely mentally ill.
• Those with serious mental illness are dying earlier of preventive conditions exacerbated by metabolic effects of drug treatment on a catastrophic scale.
Meanwhile, primary care is under-resourced to cope with the massive demand for mental services for those with milder or moderate mental distress, according to a new position statement published on Friday by the Australian Medical Association. The statement outlines a crisis-driven system at all levels of patient severity that requires fundamental restructuring and greater resourcing from general practice to psychiatry.
“Mental healthcare is already chronically underfunded, and severe workforce shortages and inadequate staffing, the complexity of presentations, and increasing patient loads are further contributing to a system reaching breaking point,” AMA president Danielle McMullen said. “People desperately need help; we need to take this crisis seriously. We need all governments to work collaboratively to improve the function, size and distribution of Australia’s mental healthcare workforce to ensure care is available for some of the most vulnerable members of our society.”
The Australian’s series is launched as the nation’s health ministers met in Tasmania on Friday, with mental health ministers to join another meeting next month to discuss reform.
It also comes ahead of an inquest early next year into the shocking tragedy of the Westfield Bondi Junction murders by Joel Cauchi, who was living with schizophrenia, had disconnected from healthcare and who had become itinerant, a known high-risk factor.
Cauchi stabbed and killed six people and injured a further 12, including a nine-month-old baby, on April 13 this year in the Westfield Bondi Junction shopping centre in Sydney. One of the victims was 47-year-old architect and mother of two, Jade Young, whose mother, Elizabeth Young, has taken on a brave advocacy role for national mental health reform.
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Investments in housing for those with severe mental illness would reap enormous gains and savings for the nation.
Shocking plight of mentally ill ‘a stain on nation’
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The severely mentally ill were promised a better future after asylums were mothballed. The promises were hollow.
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Australia has a chance to fix its mental health system. Will we take it?
Australia’s broken mental health system has failed hundreds of thousands of people with severe illness with ineffective care – and that’s if they can access any at all. But one initiative may shift the dial.
‘The mental health ward became my prison cell’: a patient’s plea for change
Billie spent more than 1000 days in hospital before she turned 18. Damaged but determined, she is now speaking out for mental health reform.
“In the months since April 13, the day of the murder of my daughter by a man numerous people have described as having ‘fallen through the cracks’ of society’s foundations, my family has been struggling to return to new ‘normal’ routines,” Ms Young told The Australian.
‘Just do something!’
While her family in Sydney had been supported by mental health practitioners, her son PJ, who lives in Tasmania, did not receive the same treatment.
“My despair over the loss of our gentle girl, the horror over the savagery of the attack, the overwhelming public nature of it all was compounded by my son’s inability to get the urgent critical care needed to help him and his family cope, an inability arising from the disparate forms of mental health provisions within Australia.
“The sad truth is, your postcode dictates the availability of care and its price, and my son’s postcode meant there was nothing when he so desperately needed it.
“I believe the murderous event happened because of decades of political indifference, exacerbated by a series of missteps or mistakes made by individuals in the management of the perpetrator’s mental health and wellbeing – but, critically, it stems from bad decisions made way back when deinstitutionalisation was the buzzword.
“We don’t need another inquiry, we don’t need anodyne comments, or earnest promises made in the heated atmosphere of an election year next year. We need action, action at many levels to ensure those thousands suffering from mental ill health are recognised and their needs met.
“I call out to Canberra … in 2025, don’t use my daughter’s murder, don’t exploit the horror of April 13 to further your political aspirations … don’t just talk, step up and actually do something!”
Like the Youngs, many families have told The Australian of their struggle to obtain accessible and effective healthcare across the gamut from mild to moderate depression and anxiety, to the so-called “missing middle” with complex needs, to those with acute psychotic illness.
“How would I describe the system? I would say that at times it feels like there isn’t a system at all,” says Sydney mother Bernie, who trained as a medical doctor but has struggled for 15 years to secure adequate healthcare for her daughter with treatment-resistant schizophrenia. Bernie’s second name has been withheld for privacy.
“Ultimately, there is nothing in terms of healthcare until you reach crisis.”
Families aren’t coping.
Carers have spoken of living in chronic stress, fear and worry and utter isolation amid a total lack of support in the health system.
“It’s just got to the point where many people have stopped even looking to the mental health service for help because they know it’s not going to be responsive,” says Sharon Lawn, executive director of Lived Experience Australia and supporter to carer support groups such as Parents for Change and Sanctuary.
“Some people might say ‘isn’t it the role of families to look after families?’ But you know, when it’s 11 o’clock at night and your family member is so distressed and wants to harm themselves, is suicidal, or is experiencing paranoia and wants to confront others who they think want to hurt them, it’s a little bit beyond what a family can cope with.”
The ANU-The Australian report has found that Australia needs 17,750 psychiatric inpatient beds to meet demand, but provides only 7000. The shortfall of 10,750 beds a year that is required would cost taxpayers $4.7bn a year.
However, adequate investment in supported housing for the severely mentally ill would radically slash the need for inpatient beds, with healthcare and social supports attached to housing costing orders of magnitude less than hospital care.
The unmet need for supported accommodation is estimated to be about 31,000 places nationally, the report finds, and if a building project were undertaken to meet all of the demand extending to the end of this decade, it is estimated to cost almost $6bn a year.
“The good news is that supported housing has been shown to be cost-effective through rigorous economic analysis in Australian settings,” the ANU report says.
“Data from contemporaneous Australian supported housing models shows people with severe chronic mental health conditions managed in such settings have up to a 74 per cent reduction in the need for community mental health services, reductions of more than 70 per cent in the need for hospitalisation, and – if hospitalisation is required – reductions of more than 75 per cent in length of stay.
“In a situation where there is a shortfall in mental health hospital beds of more than 10,000 nationally, the need for these beds and the associated mental health workforce would almost be obviated through the positive effects of supported housing alone.”
The system is broken
A commissioner on the recent Victorian Royal Commission into mental health, former ACCC chairman Allan Fels, who is also a former chair of the National Mental Health Commission and whose daughter lives with schizophrenia, said mental health care is broken nationwide.
Professor Fels has worked hard to expand supported accommodation to those with severe mental illness via the Haven Foundation, a non-profit organisation of which he is a board member. Professor Fels’ daughter Isabella lives in one of the Haven’s long-term supported residences in Melbourne.
“Despite heroic efforts by countless individuals, the overall system of mental health is in crisis everywhere and at every level, for all ages and for all levels of intensity, from mild to severe, but especially for persons at the severe end,” Professor Fels says.
“Many mentally ill people are homeless or live in shocking substandard accommodation. They are in and out of hospital regularly, in and out of prisons regularly. Housing for the mentally ill has been neglected ever since the closure of asylums two or three decades ago. Safe, stable, comfortable housing keeps mentally ill people out of homelessness and appallingly substandard and unsafe accommodation, out of hospitals, out of excessive use of the health system, and out of prison.
“Care and the provision of services for the mentally ill has been under-prioritised by all Australian governments, federal and state, for decades, with much higher priority being given to budget repair and interest repayments, defence, ageing, general health and disability. Mental health sadly always comes last and is at the bottom of the list of priorities.
“Proper investment in the provision of services, housing and care for people with severe mental illness would quickly pay for itself in terms of reducing public spending on hospitals and health services, disability support and prisons, and the vast sums of money that are spent on propping up the homeless.”
The ANU-Australian investigation also lays bare the size of the workforce crisis in mental health care. It finds that the nation is filling only about 70 per cent of the mental health worker positions required to meet patient demand. By 2030, four out of 10 staff positions then needed will not be able to be filled.
The most critical staff shortages are in psychiatry. Australia has a workforce of about 2800 psychiatrists despite the need for about 5000. It’s estimated $1bn a year would be required to make up workforce shortages of psychiatrists, psychologists, nurses, GPs, Aboriginal health workers, peer workers and occupational therapists.
Recent analysis by the Australian Salaried Medical Officers’ Federation found that of NSW’s 295 staff specialist psychiatrists working in public hospitals, 145 had recently sent letters of resignation to their union amid a protracted recruitment and retention crisis.
Yet NSW has the capacity to employ 416 full-time staff specialist psychiatrists and is struggling to fill 121 vacant positions.
Psychiatrists have told The Australian that those once dedicated to the public system can no longer cope with what they describe as the moral injury they suffer working in inpatient wards, and this despair was now extending to the private system.
“There has been a huge mutiny of my colleagues out of the system, especially out of the public sector,” says Sydney psychiatrist Gary Galambos.
“It’s a crisis-driven system. You can’t be therapeutic in a system like that.”
‘This is an epidemic’
Psychiatrist Angelo Virgona, an elected director of the board of the Royal Australian and New Zealand College of Psychiatrists, said chronic underfunding had left the sector in a state of near-collapse in which patients were not receiving the healthcare they deserved.
“We are slipping backwards in mental health funding as a proportion of the total health budget despite rising incidence of mental illness. Seriously, this is an epidemic,” Dr Virgona said.
The ANU economic analysis shows a further $1bn is needed to provide psychosocial supports to those living with severe mental illness. While a minority are supported by the NDIS, an estimated 650,000 people with severe and moderate mental illness are getting no social supports. This has been a key recent focus of health and mental health ministers nationwide. The challenge is now to expand the unmet need policy in psychosocial service provision to mental healthcare, housing and social services more broadly.
Endemic housing insecurity among those with severe mental illness combined with inadequate community and social supports is creating a “revolving-door” phenomenon in mental health wards, where people are discharged often to homelessness when still unwell due to pressure for inpatient beds.
The root of the problem traces back to the closure of long-stay mental hospitals decades ago. While the evidence is strong that community care is preferable for most, governments never resourced the community sector to fill the gap left by the closure of asylums, and housing insecurity is now endemic among those most severely affected by mental illness.
The costs of housing the mentally ill in jails, where they frequently end up (half of inmates report experiencing mental illness), is also huge. Forensic mental health facilities nationwide are oversubscribed, with years-long wait times to get a bed.
Forensic patients cost taxpayers about $3000 a day each in units dotted around prisons nationwide, triple the cost of being in hospital. The Northern Territory barely has any forensic facilities and incarcerates mentally ill people, and people with cognitive disability who are unfit to plead, in maximum security prisons.
In the most remote corners of the country, there are no public psychiatry services for young people, including in juvenile detention centres where up to 90 per cent of child inmates experience complex mental illness.
“The situation has sort of reached a crescendo,” said Alice Springs Hospital clinical director of mental health services Marcus Tabart, who described having to “cobble together” healthcare support for young people experiencing psychosis due to a complete lack of public funding for youth and adolescent psychiatry outside of hospitals in the NT and across remote Australia.
“The basic issue is that we don’t have a forensic mental health facility in the Territory, so when people with severe mental illness face the judiciary, and they are found not fit to plead or mentally impaired and not able to plead, and they don’t require acute hospitalisation, their disposition is the prison,” Dr Tabart said.
From coast to coast and into the remotest corners of the nation, the suffering of patients and families is vast. An opportunity now presents itself for critically needed national attention – and, most importantly, better lives for patients and their exhausted families.