Living Well - a summary
This is a summary of Living Well: A Strategic Plan for Mental Health in NSW 2014-2024. For the full version please see our Living Well - downloads page.
On this page
1. Planning for our future
2. Making it local
3. Getting in earlier
4. Putting people first
5. Providing the right type of care
6. Better responses
7. Care for all
8. Supporting reform
9. Governance of mental health within NSW
This summary presents an overview of the major themes in Living Well: A Strategic Plan for Mental Health in NSW 2014-2024. It is not intended to be a comprehensive digest of the Plan. Instead it provides an introduction to Living Well’s perspectives on the reform of services for people who experience mental illness and on how to achieve better mental health and wellbeing for everyone in NSW.
Our vision is for the people of NSW to have the best opportunity for good mental health and wellbeing and to live well in their community and on their own terms.
The values of reform
These apply at all stages of life, across all cultures and for all communities in NSW.
Acknowledging the equal value of every human life should underpin everything we do to support and promote mental health and wellbeing. In particular we must ensure that government, community-managed and private services always assure the autonomy, dignity and individuality of people who experience mental illness.
Those of us who live with mental illness have the right to expect to lead fulfilling lives, and to pursue our own choices about how we live and about the support we accept, regardless of whether we are experiencing symptoms. This should also be so for our families and carers.
Strong connections among people are the foundation of mental health and wellbeing and resilience for individuals, families and our wider society. These connections nurture social inclusion and respect for diversity and are particularly important for people who experience mental illness and for their families and carers.
In partnership with people who live with mental illness, mental health professionals, service planners and policymakers must ensure that supports and services meet contemporary standards and are effective.
People who live with mental illness should expect to be supported equally in their recovery, regardless of their age, gender, culture, sexual or gender identity, where they live or any other health problems they have.
Responsibility for individual and community mental health and wellbeing is shared across our society. All of us, whether or not we experience mental illness, should expect to contribute to that shared mental health and wellbeing, and to be able get support when we need it.
We should create an environment where people whose lives are affected by mental illness can experience the benefits of positive change and be optimistic for a better future.
The indicators of reform at a glance
We will increase
- positive mental health and wellbeing
- participation by people with a mental illness
- the peer workforce
- positive experience of service delivery
- the proportion of NSW mental health funding spent on community-based services.
We will decrease
- psychological distress in the community
- discrimination and stigma
- suicide and suicidal behaviour
- the use of involuntary treatment orders
- the proportion of people in the prison population who have mental illness.
1.1 A role for everyone
Mental health and wellbeing is an essential part of our society. It runs through everything we do. We are all affected by it and we are all responsible for it.
Mental health, wellbeing and resilience flow from social and economic participation, education employment and stable housing.
Within the NSW Government, this Plan focuses on a number of key agencies including NSW Health, Family and Community Services, Education and Communities and Justice. But all government agencies will need to consider whether their services impact on people who experience mental illness and how they manage mental health and wellbeing in their workplace. Local government also plays a vital role.
Living Well also acknowledges community-managed organisations, general practitioners, private psychiatrists, psychologists, nurses and allied health professionals.
We need to enhance and support their capacity to keep people well in the community.
1.2 The role of the Commission
The NSW Mental Health Commission is not the owner of Living Well - it belongs to the whole community. But it will have both an oversight function and an active role in reform delivery. The Commission is required to monitor and report on the implementation of Living Well, taking into account not only health services but all other policies and services that affect our capacity to have satisfying, contributing lives such as employment, housing, social inclusion, choice and autonomy.
Part of this role will involve the Commission identifying meaningful performance indicators and reporting to the NSW Government, Parliament and the community on them and, more broadly, on whether things are getting better. But the Commission will not simply be a passive observer. It will, through its other statutory roles, work with agencies on Living Well’s successful implementation.
In a state the size of NSW there is no one-size-fits-all solution. We must empower local agencies and related services to work together to plan delivery of services around local needs. We also need to better recognise the particular strength of Aboriginal healing through culture and strengthen partnerships between Aboriginal communities and service providers.
The NSW Government is already making changes that will support stronger local responses. The NSW 2021 plan has promoted regional development plans and cross-government initiatives to facilitate alliances and actions. A number have already made mental health a priority and have projects under way.
To harness the potential of local action to support better mental health and wellbeing, we will need support from government and agencies at all levels. For local collaborations to be sustainable, there need to be reliable benefits to all contributors.
In the longer term, this will be seen through improved outcomes for individuals and reduced costs to the community and government.
For the biggest impact we need to target regions and communities with the greatest and most entrenched mental health and social disadvantage. We need to understand how inequalities cluster in geographic areas, and how these relate to poorer mental health.
2.1 Aboriginal communities
Aboriginal culture promotes wellbeing, positive social relations and shared responsibility through its emphasis on family, community, respect and connection to land. It has proved its resilience by surviving intact and strong through many millenniums and through two centuries of injustice and cruelty, including violence, dispossession of land, imprisonment and the removal of children.
This exceptional culture continues to guide, sustain and console Aboriginal people but they still struggle with racism, discrimination, pervasive disadvantage and the continuing grief and trauma of a culture that honours ancestors and still experiences the early and preventable illness or loss of family members.
These experiences are important factors in the significantly worse mental health of Aboriginal people compared with other members of the community, and they will need to be acknowledged and addressed for this situation to improve.
In 2011 an estimated 208,500 Aboriginal people lived in NSW, comprising 2.9 per cent of its population and nearly one-third of the Aboriginal population in Australia.
About 20 per cent of Aboriginal adults in NSW experience high or very high psychological distress, including depression and anxiety, which is twice the rate of non-Aboriginal adults.
In NSW, the overall rate of suicide for Aboriginal people is 1.4 times higher than for non-Aboriginal people. During 2011 and 2012, the rate of hospital admissions for Aboriginal people in NSW for intentional self-harm was more than three times the rate for non-Aboriginal people and has increased by more than 50 per cent since 2001 and 2002.
Aboriginal children and young people also suffer poorer mental health than their non-Aboriginal counterparts, highlighting the need for early detection, appropriate referral and culturally appropriate programs.
The NSW Mental Health Commission has heard from NSW Aboriginal communities throughout the state that Aboriginal people are concerned about:
- access to mental health support that is culturally appropriate, including the need for more Aboriginal mental health workers and respect for women’s business and men’s business – circumstances when men and women should not mix.
- the capacity of Aboriginal communities to respond to the high rate of mental illness and suicide.
Efforts to support Aboriginal mental health and social and emotional wellbeing must be grounded in respect for Aboriginal self-determination. Government programs must be co-designed, implemented and managed in partnerships with Aboriginal people and communities.
Healing within Aboriginal communities must be driven by individuals and communities and cannot be directed or imposed by government. However, the NSW Government does have a role in encouraging healing and wellbeing in Aboriginal communities.
The individual, social and economic costs of mental illness are immense, so promoting mental health and wellbeing makes good sense. This includes providing individuals with the tools they need to care for themselves and building supports across the community, including in the workplace. For long lasting change we must start early by improving the supports available for vulnerable children and their families.
3.1 Building community resilience and wellbeing
The resilience that comes from good mental health and wellbeing is the foundation of:
- safer and healthier families, schools, workplaces and communities
- higher educational achievement
- improved relationships and personal dignity.
Promoting wellbeing for everyone means targeting those social factors that foster good mental health and the development of resilience, including access to housing, education, employment or other meaningful activity when employment is not available.
3.2 Promoting self-agency
Most of us are able to take care of most of our emotional and wellbeing needs without accessing formal services. Self-agency is about individuals taking charge of their health and wellbeing in their homes, neighbourhoods and communities.
People who experience mental illness have enormous capacity to influence their health outcomes with quality information and appropriate self-management tools. E-health interventions can effectively support some people to manage their mental illness.
However the NSW mental health system often reinforces an illness model instead of focusing on good health. This represents an important opportunity for change.
3.3 Prevention and early intervention for children and young people
Signs of vulnerability to mental health issues are often clear by the time a child turns six. Patterns of drug and alcohol misuse and eating disorders commonly start in adolescence. Half of all mental illnesses manifest before age 14 and three quarters by age 25.
- In 2012, 8.3 per cent of NSW children were found to be developmentally vulnerable because of their low emotional maturity when they started school.
- In 2011, 14 per cent of secondary school students exhibited signs of high psychological distress.
There are untapped opportunities to intervene early in circumstances that may undermine the mental health and wellbeing of children and young people in NSW.
The challenges a parent faces, such as financial hardship, domestic violence, postnatal depression and drug and alcohol misuse, expose children to greater risk of developing mental health and behaviour problems. Pre- and post-natal medical care, early education, specialist mental health services for children and young people, and intensive family support services can play an important role.
3.4 Suicide prevention
Suicide exacts a terrible toll on individuals and those closest to them, and on entire communities. Australian Bureau of Statistics data from 2012 indicates 707 people in NSW completed suicide during that year. Each year about 9000 people are admitted to NSW hospitals for intentional self-harm.
Local communities want to know how to support those bereaved by suicide and how to become more resilient. Well-informed, community-based action backed by evidence and professional expertise needs to be a cornerstone of suicide prevention activities.
People who have survived a suicide attempt or are bereaved as the result of suicide will have a vital role in shaping prevention efforts. Better data on suicide and suicide attempts will also be essential, along with better responses within the health system and from front-line staff.
3.5 Mental health and wellbeing in the workplace
Practices that promote mental health and wellbeing need to become as embedded in workplace culture as those that surround physical health and safety, and collaboration between government and industry will be required to achieve this.
For many people with a mental illness, workforce participation is an essential part of the recovery journey. By contrast, unemployment can lead to social exclusion, economic disadvantage, poor mental and physical health, and housing instability. Many people with mental illness want to work, and a range of options for workforce participation and social inclusion is required.
We gain much from listening to the concerns of people living with mental illness and their families and carers and we need to routinely include them in service design.
4.1 Engaging consumers and carers in service design
The benefits of designing services in collaboration with consumers, families and carers, whether housing, health or other human services, include:
- services and staff develop a better understanding of mental illness and of working towards recovery
- staff experience greater job satisfaction
- consumers are more likely to have better mental health outcomes.
4.2 Families and carers
Family members and carers are in a unique position to contribute to a person’s recovery. They can support people to live well in the community and enhance the effectiveness of service delivery. This helps to decrease the risk of episodes of acute illness and the need for hospital admissions. We must ensure family members and carers also get the support they need.
4.3 Build the capacity of services to respond therapeutically
People with a lived experience of mental illness and trauma, and their carers and family, often find government agencies and services difficult to navigate and are likely to require additional support to do so successfully. Without understanding clients’ needs and appropriate training, government agencies and their front-line staff cannot effectively respond. People who live with mental illness may avoid difficult interactions with service providers and risk not getting the support they need.
4.4 Responding to trauma
Many people do not connect their current problems and behaviours with past traumatic experiences – and nor do those who provide services. Even when trauma is identified, many services do not give the person the support they need.
We need a service system that understands trauma and responds appropriately. Such a system would focus on ensuring services do not re-traumatise or blame people for their efforts to manage their traumatic reactions but understand a person’s behaviour in the context of their life experiences and attempts to cope.
Hospital-based mental health care is one part of a good mental health system, but it should be a back-up used on rare occasions when community-based support is not feasible. This approach is consistent with our human rights obligations and our NSW 2021 goal of keeping people out of hospital and well in the community.
NSW remains overly reliant on hospitals in the delivery of mental health care. While funding for community mental health care in NSW has increased, most mental health sector spending occurs in expensive acute hospital settings.
Under this Plan, community-based care and support will become the focus of the mental health system.
5.1 A better community-based system
An effective community system wraps services and support around people living with severe mental illness. This includes assertive outreach, with mobile treatment and crisis resolution teams and whole-of-person support services, a variety of residential alternatives to hospital, and less reliance on involuntary treatment orders.
It also requires strong integration and partnership among clinicians in hospitals and in the community, such as general practitioners, private psychiatrists and other care providers.
5.2 Commitment, resources and collaboration
Developing a contemporary, community-focused, integrated mental health care system will require commitment, human and financial resources, and co-operation and collaboration at the community and state level. We need a system that directs energy and resources towards services outside hospital, delivered close to home.
The community mental health service must include step-up and step-down care as an alternative to inpatient admission or to provide support after an acute episode of illness.
For community-based care to be effective, we must ensure:
- easy access and availability of services
- co-ordination and continuity of care
- early detection and intervention
- evidence-based medical and psychological treatments
- safety and risk management
- acute and emergency interventions
- rehabilitation approaches that support social inclusion
- opportunities for learning, employment, housing and social relationships.
In 1983, a NSW inquiry recommended that long-stay psychiatric hospitals should be gradually reduced in size and replaced by “a system of integrated community-based networks, backed up by specialist hospital or other services as required”.
However, while some long-stay psychiatric units were subsequently closed, the community-based networks have not been fully developed. Long-term institutionalisation is a continuing practice, and some stand-alone psychiatric hospitals remain. In February 2014, there were 2337 mental health inpatients in the NSW public health system and a quarter of them, or 566 people, had been in hospital for more than a year.
5.4 Into the community
With the right community-based support, including that offered under the National Disability Insurance Scheme, the vast majority of long-stay patients in NSW will be able to return to live in the community. Some will require supported, community-based accommodation, such as that offered under the Housing and Accommodation Support Initiative. A minority will require long-stay care in a safe, supported environment, outside an institutional setting.
5.5 Reinvesting in mental health
Stand-alone psychiatric institutions represent a misguided investment in mental health but an investment nonetheless. They were places of great suffering for people with mental illness and many in our community remain traumatised by their experiences.
There is therefore a strong moral argument for the Government to ensure that any funds from their sale or re-use are used to address the substantial remaining need for community-based alternatives to hospitalisation.
5.6 Addressing inequalities
People living with mental illness can face significant issues when needing to travel to health services – sometimes because of symptoms associated with their illness and the side effects of medication. This is more difficult where public transport is limited or unavailable, such as in remote and rural areas.
There are also significant service gaps for:
- people in rural and remote NSW
- Aboriginal people
- young people
- older people
- people from culturally and linguistically diverse backgrounds
- lesbian, gay, bisexual, transgender and intersex people
- people with complex problems, such as eating disorders, who need specialist treatment
- people with multiple issues, for example, when mental illness and intellectual disability affect each other.
It is not possible for uniform service provision to exist in every area or across all age groups. Nonetheless, we should strive for equality of access and quality.
Services across government should respond in a therapeutic and integrated way to meet the needs of people who experience mental illness. This approach improves people’s physical and mental health, helps in their recovery, and saves money.
6.1 Physical health and mental health
People who experience serious mental illness are at higher risk of physical health problems, including heart disease and diabetes, than the general population. GPs are well placed to support the physical health of people with mental illness. They also have responsibility for addressing the mental health needs of people with physical illnesses. Specialist mental health clinical services must also take responsibility for the holistic care of the people they support. Health system policies and local service development will need to make room for integrated and shared-care programs.
6.2 Integrating mental health and drug and alcohol responses
Drug and alcohol problems, especially when they are more severe, frequently go hand in hand with mental illness. And once mental health and drug and alcohol problems have become established, they can perpetuate and exacerbate each other.
Drug and alcohol misuse makes it harder to recover from mental health problems. Equally, mental distress makes dealing with a drug and alcohol problem more challenging. The presence of both may also complicate treatment, leading to the need for more intensive services – including hospital treatment – and poorer results.
Despite what we know about the intimate relationship between them, we continue to respond as if mental illness is separate from drug and alcohol misuse. This Plan seeks to accelerate efforts to better co-ordinate mental health and drug and alcohol services.
6.3 Housing and homelessness
We know there is a strong relationship between homelessness and mental illness. This problem is particularly felt by young people, and it is estimated that 50 to 75 per cent of homeless youth in Australia have some experience of mental illness. Initiatives to improve housing stability and prevent homelessness among people experiencing mental illness must be guided by people’s housing preferences.
There is a particular need to re-focus resources from temporary crisis accommodation to effective prevention and early intervention strategies.
6.4 Bringing a holistic therapeutic approach to youth justice
About 90 per cent of young people in custody have at least one psychological disorder, such as a personality disorder or mood disorder, and about 70 per cent have two or more. Young people in custody often have behavioural problems such as poor impulse control, aggression, lack of empathy and difficulty making good decisions, often stemming from neglect or abuse.
Custodial sentences offer an opportunity to establish therapeutic interventions that will benefit the young person and the community, but the real goal with young people must be to develop holistic early interventions that reduce the possibility of their coming into contact with the criminal justice system. And, for those who do come into contact with the criminal justice system, diversion from it wherever possible is a desirable alternative and long-term goal.
6.5 Improving access to services for adults in custody
People with mental illness are over-represented in the criminal justice system, but there is no simple relationship between mental illness and crime. Other factors, such as disrupted family backgrounds, family violence, abuse, drug and alcohol problems and unstable housing, are often part of the picture. Forensic patients, and Aboriginal people and women with mental health problems, are particularly vulnerable within the criminal justice system.
A short period of custody should not interrupt the continuity of care a person might have had with a community service provider. Where possible that service should follow the person into prison. Alternatively, where a person in custody is identified as having a mental illness, they should leave custody linked to a community-based service.
Many groups within our community have particular mental health needs, on account of their culture, or a disability, or because their mental health problem falls outside mainstream service provision.
7.1 Lesbian, gay, bisexual, transgender and intersex mental health
This higher risk of mental illness and suicidal behaviours for LGBTI people flows from the stigma, discrimination and marginalisation they experience. This is sometimes referred to as minority stress and occurs across genders, and in both youth and adult populations. Despite some legislative and social improvements, there is still a very high experience of homophobic and transphobic discrimination and exclusion, both within families and in the broader society. LGBTI people continue to be a very marginalised group.
7.2 Multicultural NSW
The experience of migration varies hugely and mental health varies among people from culturally and linguistically diverse (CALD) backgrounds as it does within the population at large. But we also know that particular experiences – such as living through violent conflict in your country of origin – place some people at higher risk of mental illness. The stigma about mental illness that still exists within established CALD communities can also make individuals reluctant to seek help for themselves or their loved ones.
There is also an urgent need to address language barriers and cultural differences and sensitivities. This means mental health services, government and other relevant agencies will require comprehensive training to improve their understanding and responses, and people from CALD backgrounds who have lived experience of mental illness will be invaluable to this process.
7.3 Mental health and intellectual disability
The impact of intellectual disability on a person’s functioning varies greatly from person to person and increases if the person also has a mental illness. People with an intellectual disability experience very poor mental health compared with the general population. Up to 40 per cent of people with an intellectual disability have also experienced a mental illness.
A sharper focus is required on policy and program development for the mental health needs of children and young people with an intellectual disability. This should include tailored prevention and early intervention programs and services that offer timely and skilled mental health assessment and intervention.
7.4 Eating disorders
While predominantly affecting adolescent girls, eating disorders occur across all genders and ages, with increasing diagnoses in younger and older people.
Gaps in service availability, poor service integration, and regional differences have been identified with significant barriers to access in regional and rural communities due to social stigma, lack of professional expertise in treating eating disorders and lack of services. Despite a recent increase, there are still insufficient specialist beds to meet people’s needs, particularly in regional centres. This is exacerbated by a lack of community-based services.
7.5 Borderline personality disorder
It is estimated that borderline personality disorder (BPD), which is associated with emotional distress, relationship difficulties and self-harm, affects 1 to 2 per cent of the population. People living with BPD often have chaotic personal circumstances and are ambivalent towards treatments and supports. Services and staff members need to be oriented and educated to help people with BPD, recognising that specialist services are required for the most complex instances.
8.1 Investing in our workforce
Our workforce is the heart and soul of the mental health system. To support people who experience mental illness we need a mental health workforce of the right size and with the right characteristics to meet the demand for services, both in the community and in hospitals.
We also need our mental health workforce – including Aboriginal mental health workers, GPs, mental health nurses, occupational therapists, social workers, psychologists and psychiatrists – to understand and support the philosophy of recovery and to have the skills and tools to provide services that are recovery focused.
We need to build a vibrant professional community mental health workforce that eases the pressure on acute crisis services and enables consumers to find care and support closer to home. We need a new way of arranging our workforce to make the most of people’s skills. This will require:
- rapid growth of the peer workforce
- strategies to ensure the most efficient use of the scarce specialist clinical workforce, including relieving people of non-clinical work
- workforce planning that acknowledges the different demands of community-based care and recovery-oriented practice
- better integration of GPs within our mental health system.
8.2 Peer workforce
Employing people with lived experience of mental illness in peer worker roles to support others brings a tremendous range of benefits. Peer workers know what it is like to live with mental illness and can share experiences of their recovery with others. People who are living well with mental illness represent hope that is often missing in people’s lives. Peer workers, consumer advocates and consumer representatives have been employed by the public mental health sector for 20 years but they are not always well accepted. Stigma and discrimination can cause a divide between the peer workforce and other staff.
Formal structures, policies and procedures are needed if government services are to realise their full potential of peer workers. At present, the peer workforce in NSW is small, under-supported and under-resourced.
8.3 Developing the community-managed sector
NSW needs a strong and resilient community-managed organisation (CMO) sector if it is to build strong alternatives to hospital care. The development of this sector will also allow NSW Health to make best use of scarce specialist clinical skills.
But in NSW, CMOs have to prepare for a shift from a system of government grants to competitive tendering arrangements. Many are also adjusting to the new requirements under the National Disability Insurance Scheme. The survival and growth of the sector will depend on its capacity to adopt new business models and on the continued professionalisation and accreditation of its workforce.
8.4 Better use of technology
Providing the best mental health care in the 21st century means embracing new technologies to help deliver care and to expand access to it. It means harnessing new technology to promote self-agency and consumer choice, and supporting clinicians and service providers with new tools to improve care, data collection and information sharing.
For people who experience mental illness, online access to care and support has the potential to make a real difference. This is particularly true for people in rural and remote areas and for those who prefer not to use face-to-face professional services for cultural reasons or because of stigma. An overwhelming majority of Australians – 86 per cent – use the internet, with 44 per cent using it more than five times a day. Ninety-five per cent of young people use the internet daily.
New technologies that support consumers in their recovery will allow specialist mental health services to focus more on people with severe and debilitating illness. In addition, better clinical information systems and decision-making supports will improve the quality of care.
We need to make sure resources are appropriately directed for change to take place.
Mental illness has until very recently been viewed in our community as something quite separate from a person’s general health and other aspects of their life. That separateness has been echoed in the systems that have grown up in NSW to offer mental health care, which have existed in parallel with our broader system of public health care. We need an integrated approach to planning, development, and governance across the whole of the public health system that is fully inclusive of mental health.
9.1 Funding is critical to the reform agenda
There have been long-standing calls for mental health funding to be quarantined and successive commitments to ensure that this is so. Concern for the protection of mental health budgets was central to Parliament’s support for the establishment of the Mental Health Commission of NSW.
Government should have a clear sense of what it wants to achieve, and the resources it is investing through the Local Health Districts (LHDs), which will have to increase their focus on mental health service innovation and change. LHD directors of mental health will need authority to act, including having certainty around their budgets.
The development of Living Well comes at a dynamic time in the development of health and social policy, at state and national levels. Major policy revisions, based on new philosophies about individual autonomy and effective service provision, have the potential to dramatically change the way support is offered to people who experience mental illness, and to rewrite our shared understanding about community wellbeing.
But these policy transformations also make it more difficult to anticipate the shape of the future. We will revisit Living Well at intervals during its 10-year horizon, to check that it is achieving the improvements we expect.
Some of the most important current policy directions, which may affect our thinking and practice in mental health and wellbeing, include:
10.1 National Disability Insurance Scheme
Under the National Disability Insurance Scheme (NDIS), people with a psychiatric disability will be offered support if their impairment affects their communication, social interaction, learning, mobility, self-care or self-management, and the impairment affects or is likely to affect the person's capacity for social or economic participation. The NDIS acknowledges severe psychological symptoms can be just as disabling as physical illness.
10.2 Activity-based funding
Mental health services have been block funded, receiving from Government last year's funding plus or minus a little. This is being phased out and replaced by activity-based funding (ABF), which takes into account the number of episodes of care and allocates more funding for patients whose care is more complex.
- Living Well reforms
- Living Well - Plan and Report
- Our priorities