There is a crisis in mental health in Australia. Its magnitude, and community concern over it, is reflected in the 500-plus submissions made earlier this year to the Federal Government’s Senate Select Committee on Mental Health. In this article we draw on several of these submissions to highlight the critical issues facing mental health care in Australia.
First, the crisis in mental health services is closely related to severe problems in the mental health workforce. When conducting a recent survey about the health workforce, we found that those interviewed emphasised the shortages that currently exist across all the mental health professional groups, including psychiatric nurses and psychiatrists. The number of psychiatrists entering the workforce each year, for example, is failing to meet the targets set by the Royal Australian and New Zealand College of Psychiatry (RANZCP).
The supply of new graduates from all the health professions into the mental health sector is low, nursing in particular. It is estimated that nationally only 4 per cent of new graduates are entering the mental health system. Of those who do enter many quickly leave. Many parts of the workforce are now dependent on attracting overseas trained graduates.
Health Services Union
Currently, there are 12.1 psychiatrists per 100,000 of the population in Australia, but only three psychiatrists per 100,000 Australians in training. SANE Australia believes that the low numbers of graduates entering the mental health workforce follows widespread demoralisation of mental health workers, created by their low status within the health system, heavy workloads and poor training.
The current general practitioner workforce cannot meet the need for patients requiring treatment for patients with common mental health problems… With 950,000 Australians requiring treatment for depression, the total intervention for this group would be 3.325 million hours per year. Given this, and evidence that general practitioner workload is also increasing as the age of Australia’s population is increasing, the capacity for general practitioners to expand their current role further without substantial systemic changes that might enable such expansion, is extremely limited. These figures demonstrate that even the largest medical workforce in Australia cannot currently accommodate the burgeoning requirements of managing common mental health illness in general practice.
Royal Australian College of General Practitioners
These problems are compounded by problems in other mental health professions such as psychiatric nursing where the workforce is both ageing and failing to attract enough new nurses. Two areas that most keenly feel the impact of workforce shortages are rural health and the public system.
Despite 30% of the Australian population living in rural and regional Australia, only 15% of psychiatrists work in these areas. Indeed only 3% of all psychiatrists work outside capital cities or major regional centres, meaning that there is one psychiatrist for each million people living outside cities or regional centres as opposed to twelve per 100,000 for the population as a whole. They are also distributed unequally among the States. The Northern Territory, for example, has 5.9 psychiatrists per 100,000 people – while Victoria has three times that number. These inequalities are associated with higher rates of mental illness in many rural and remote areas. The suicide rate for men aged between 15 and 24 in remote areas is, for example, more than double other parts of Australia – 76 per 100,000 compared to less than 30 per 100,000.
Because of poor rural mental health services, the care of the mentally ill falls to others, including general practitioners, emergency departments, or other community care organisations. Ill-equipped rural hospitals often find it difficult to find appropriate care for patients with acute mental illness. . When psychiatric services are available in rural areas, they are provided by outside consultants who visit the community infrequently and cannot offer sufficient contact needed for ongoing care. HCRRA notes that while,
‘…the medical side of mental health care is tackled successfully in rural and remote areas by fly-in fly-out personnel, [but] there is not the on the ground support staff – case workers, social workers etc, to support these efforts. It seems that if the support services are not available then the good work done on the medical side of the illness unravels quickly’.
This means that on top of the added burden placed on the family members of the mentally ill living in rural areas most are unable to access support or respite for themselves.
Mental Health in the Public System
The Australian Medical Association (AMA) has openly criticised the mental health system in Australia, claiming that the system is ‘seriously dysfunctional’. Bed shortages across the country are so chronic that only those who are in extremely dire circumstances can be treated in hospitals. As the Brotherhood of St Laurence notes,
‘…consumers spoke of being refused hospital beds even though they were at a crisis point, only to be admitted a few days later in an acute psychotic state…At present, help is reserved for the most psychotic episodes only and that prevention of early intervention is of a low priority. Acute psychiatric services are under-funded, rationing access to a point where people have to beg for assistance.’
Several health experts interviewed in the Australian Health Policy Institute (‘AHPI’) workforce study commented that the public mental health system had become a revolving door for those with mental illness. Only very complex cases were seen in the public system; their admissions were brief and focused solely on stabilisation through medication.
For patients with less serious mental health problems, such as depression and anxiety which may not be life-threatening but can nevertheless impact significantly on the lives of affected individuals and their families, the prospects for receiving adequate care are limited. In fact, these patients are often unable to access public mental health services at all. As one respondent from the AHPI interviews commented,
‘The fact is that because the public health system cannot accommodate more than the critical demand cases, the less demanding cases have to go somewhere else, and that’s OK if they’ve got the resources, but where they haven’t they end up not being treated effectively and become non-productive parts of the population.’
Staff currently employed within the public mental health system are working in stressful, unfulfilling and dangerous work settings. Their focus is on treating acute mental health problems only and their workloads are very high due to understaffing. The workloads of community case managers illustrate the point. In some States, community clinicians manage the cases of up to 90 clients with mental illnesses at one time. Such workloads lead to further attrition of the workforce and discourage new graduates from entering the public mental health workforce.
As in rural areas, shortages in the public system mean that work is pushed to other parts of the health system, such as hospital emergency departments, ambulance services and community health care workers. Often people working in these areas have little or no experience managing mental health issues and the settings in which they provide care are also often inappropriate for patients. Treatment for patients with mental health problems is often shifted outside the health system altogether with mental health management falling to community services and the police, whose services are not equipped and staff unqualified for caring for the mentally ill. Police comment that they have become the de facto crisis mental health teams in many places. Concerns over the far higher rates of incarceration among the mentally ill cannot be helped if the ‘primary carer’ for them when acutely ill is the police force.
To effectively manage workforce issues it is imperative to scope and benchmark the mental health service system and come to agreement on what constitutes an adequate level of care. At present no such benchmarks exist and makes workforce planning an exercise in guesswork. We strongly recommend that a project is funded to establish a benchmark for the delivery of mental health services in Australia.
Royal Australian and New Zealand College of Psychiatrists
Despite a plethora of working groups, advisory councils and state and national inquiries, the problems facing the mental health workforce are getting worse. National solutions are needed that concentrate on investing in mental health care and developing a workforce appropriate to current and projected needs. Currently it is difficult to accurately predict future or even current workforce needs because of a poor understanding of what is needed and when. The AMA states that,
‘Funding and workforce issues are inextricably linked [and]…must be addressed as two sides of one coin. Funding initiatives without complementary workforce measures risk wasting money. Workforce initiatives without complementary funding measures risk wasting people. If we do not plan complementary funding and workforce initiatives, then we are planning for more failure.’
According to the Centre for Psychiatric Nursing, Research and Practice, Australia is lagging behind other developed nations in terms of funding. Currently, 7% of the total health budget is directed to mental health when RANZCP estimates that mental illness accounts for 27% of all disability costs in Australia. RANZCP believe that a major injection of funds is needed to ‘fix’ the mental health system in Australia, stating:
‘Ideally one billion dollars per year is required to reform existing mental health service systems, ensure a sustainable workforce, address equity issues and ensure the provision of an agreed level of service delivery in all geographic areas.’
The current workforce shortages will require new cadres of health and social support staff to provide optimal care. RANZCP, unlike other specialist colleges, recognises the significant limitations of the current mental health workforce. In response they have emphasised that they are open to change and the development of collaborative models of service provision, stating that the, ‘…RANZCP would also support a re-evaluation of the roles and domain of the psychiatrist and improved collaboration across the mental health and medical disciplines, and with consumers and carers.’ This is a refreshing change given many other specialist colleges have been unwilling to collaborate with other professions to assess how the workforce may adapt to current shortages. Creative models of service provision, such as the further use of tele-medicine for access to psychiatric assessment in rural areas, also need to be trialled and properly assessed.
Change to the mental health workforce can only happen through dialogue and cooperation between all players – Federal and state governments, psychiatrists, nurses, other allied health professionals, carers and not least the consumers. With mental health problems now one of the leading causes of disease and injury in Australia, it is imperative that real and effective policy reforms are made to the public mental health system.