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Mental health reform does not happen in a vacuum. What we do now builds on the work of previous generations – in NSW, Australia and overseas – to make things better for people who experience mental illness, and it requires us to be frank about both their successes and their failures.
The 1983 Inquiry into Health Services for the Psychiatrically Ill and Developmentally Disabled led by David Richmond for the NSW government was a landmark. Mr Richmond, a highly experienced public administrator, had previously worked closely with community-based psychiatrists and social workers providing services to public housing residents.
The report enshrined the notions of deinstitutionalisation and integrated community-based care networks, setting in motion major changes in NSW. Mr Richmond identified – as we do again in this report – the need to fund and provide services that allow consumers to remain “in their normal community environment”, and recommended – as we now do – a parallel reduction in the use of specialist psychiatric hospitals.
Mr Richmond emphasised the critical importance of funding and training of front-line staff, and recommended a move towards local responsibility for services. He anticipated the need for co-ordination across government departments and agencies to respond to social as well as health needs; in this Report we develop these ideas, providing examples of how this can work in practice and bringing in the growing role of community-managed organisations.
We are also indebted to the Richmond report for raising ideas of “people’s rights” and “normalisation and integration”, within the public conversation about mental health support. These ideas, which originated with consumers and advocates, have evolved into our present understanding of recovery.
The first Australian human rights commissioner Brian Burdekin released the report of the National Inquiry into the Human Rights of People with Mental Illness a decade after the Richmond report. Mr Burdekin said his inquiry was prompted by evidence presented to the earlier National Inquiry into Homeless Children, Human Rights and Equal Opportunity Commission (1989), which suggested the human rights of individuals affected by mental illness were routinely ignored or seriously violated.
He attributed this in part to ignorance and misconceptions about the nature and prevalence of mental illness, and to a widespread belief that people with mental illness did not recover. Groups including Aboriginal people, children, those in rural or isolated areas and prisoners were particularly likely to experience discrimination and “violations of the most fundamental rights”, Mr Burdekin wrote.
The money that should have been redirected to community mental health after the closure of institutions that followed the Richmond report, had not materialised, the Burdekin report found, while a lack of co-operation among government and non-government agencies, and the private sector had contributed to a lack of appropriate services.
Like Mr Richmond, Mr Burdekin nominated employment opportunities and housing as critical to people who live with mental illness, and called for greater focus on prevention and early intervention and the rights of carers. He highlighted the need for mental health legislation grounded in the human rights of people with mental illness.
In a 2002 report by the NSW Legislative Council’s select committee on mental health, Brian Pezzutti highlighted a need for stronger governance to protect the needs of people with mental health problems within the wider health system.
He called for regional mental health directors to have direct authority over mental health budgets, and for health regions to include in their annual reports both their mental health funding allocations and direct expenditure.
Notions of recovery, resilience, choice and human rights for those experiencing mental illness, as described in the Richmond and Burdekin reports, are at the heart of reforms being implemented across Australia.
Western Australia created Australia’s first mental health commission in 2010, paving the way for reform initiatives set out in the strategic plan Mental Health 2020: Making it personal and everybody’s business. The reforms are built on principles of respect and participation; engagement; diversity; quality of life; and quality and best practice.
South Australia’s Mental Health and Wellbeing Policy 2010-2015 focuses on recovery, a whole-of-community approach and a commitment to ongoing development of partnerships with government and community-managed organisations, consumers, carers and the general community. The policy supports targets set out in the statewide plan and builds on actions set out in Stepping Up: A Social Inclusion Action Plan for Mental Health Reform 2007-2012.
Queensland’s Plan for Mental Health 2007-2017 promotes collaboration among agencies including housing, education, training, employment, community support, health, corrections, justice, disability, police, emergency services and child safety, and endorses an expanded role for the non-government sector in community-based care and support. Queensland established its Mental Health Commission in 2013.
Tasmania’s Mental Health Act came into effect in February 2014. The legislation enables people to make choices about the support they receive, while facilitating treatment for others who lack decision-making capacity – if they need it for their health or safety, or for the safety of others. The Act also recognises the important role of carers and family members of people with a mental illness.
Australian Capital Territory’s Charter of Rights promotes the interests of people who experience mental illness by outlining their right to respect, safety, communication, access, participation and privacy. It augments the ACT’s Human Rights Act 2004, requiring public authorities to protect human rights and take account of human rights in decision making.
Victoria’s Mental Health Reform Strategy 2009-2019 signals that Victoria is determined to improve social and economic outcomes for people with mental illness and their families and carers. This reflects principles underpinning A Fairer Victoria, a plan to reduce disadvantage and strengthen social inclusion.
Northern Territory‘s Mental Health and Related Services Act 1998 was informed by the United Nations Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care (1991) and the national Mental Health Statement of Rights and Responsibilities (1991).
When the 194 member states of the United Nations adopted the World Health Organisation’s (WHO) Comprehensive Mental Health Action Plan 2013-2020, they committed to mental health foundations of prevention, social equity, community and recovery.
The WHO plan sets out aspirations and a timetable for change. It supports the notion of comprehensive, integrated services in community-based settings and recognises the need for effective leadership and governance, strong research, and human rights protections for people who experience mental illness.
The plan moves away from the concept of mental illness as a medical problem and addresses the need for opportunities for education, employment, housing and social services, presenting them as critical to people’s ability to live well according to their own choices. It argues for partnerships among public sector agencies, community-managed and private sectors in areas such as health, education, employment, legal, housing and social services.
It also describes a central role for people who experience mental illness in mental health advocacy, policy, service planning and provision, legislation development, monitoring, research and evaluation.
WHO says people with a lived experience of mental illness should be able to exercise the full range of human rights, find high-quality, culturally appropriate health and social care when they need it, enjoy good general health and participate fully in society and work, free from stigma and discrimination.
The British Department of Health’s No Health Without Mental Health strategy was published in 2011 and is underpinned by principles of freedom, fairness and responsibility. The idea of choice is also key.
Like NSW, England is addressing this next generation of mental health reform with the acknowledgement that things are already much better than they were in the past. For the future the strategy calls for acceleration in the pace of change, and increasing devolution to local rather than centralised decision making.
These reforms are intended to minimise bureaucracy, empower communities, support more personalised service packages, increase local accountability for spending and services, promote more diversity of service providers and increase social inclusion.
Released in 2012, Changing Directions, Changing Lives talks about recovery, prevention, choice, removal of barriers, engagement, community, removing stigma and listening to those who have a lived experience of mental illness.
The strategy, developed by the Mental Health Commission of Canada, describes recovery as the ability to live a satisfying, hopeful and contributing life, even when there are continuing limitations caused by mental health problems and illnesses.
Canada’s strategy calls for people living with mental illness and their families to become more engaged in the planning, delivery and evaluation of mental health services, and for increased funding with an emphasis on services proven to make most difference in people’s lives. It advocates for the public sector to become a model employer in creating workplaces that support mental health, and for all Canadians to accept responsibility for reducing stigma about mental illness.
The Canadian strategy emphasises the importance of honouring personal stories – to inform policy development but also to affirm and acknowledge a person’s experience, both positive and negative, of mental health care and support.
Blueprint ll – Improving Mental Health and Wellbeing for all New Zealanders (2012) extended the recovery approach advocated in the first blueprint in 1998 to include people with less acute mental health issues and those whose mental illness is complicated by alcohol and drug use.
It emphasises the role of family and the community in partnering with professionals in the support process, and the need to see psychological support not simply as a health activity but integrated across government and non-government agencies, including employment, education, housing and social inclusion.
It prioritises the reduction of stigma and discrimination, early intervention and improved support for people with severe, complex or episodic mental health needs, and calls for more focus on improving the experience of care and recovery for consumers.
The Commission formally acknowledges all individuals in NSW, Australia and the world who have contributed to the mental health consumer movement, for without them reform would not be possible. The voices of people who experience mental illness are the heart and soul of reform. The participation and joining of forces of everyone in the community must occur to achieve positive systemic change in mental health.
Although this change has been frustratingly slow, the consumer movement in Australia has had some major achievements. They include:
- focus of consumer rights under the First National Mental Health Plan
- development of consumer advisory groups in every state as part of the First National Mental Health Plan
- development of a national statement of rights and responsibilities (1991 and revised 2012)
- development of the Charter for Mental Health Care in NSW
- commitment and development of A National Framework for Recovery-Oriented Mental Health Services
- establishment of the National Mental Health Consumer and Carer forum in 2002 by the Australian Health Minister’s Advisory Council’s Mental Health Standing Committee
- support for the development of the national consumer organisation
- support for the establishment of Mental Health Commissions
- appointment of people with lived experience of mental illness as commissioners (National Mental Health Commission) and deputy commissioners (Mental Health Commission of NSW)
The motto “nothing about us without us” was adopted by the consumer movement and emphasises the need for consumers to be at the table in decisions that affect them.
We all owe the consumer movement recognition for ensuring that mental health care now and into the future is: beginning to be based on human rights; moving away from coercive treatment and; becoming more recovery focused; will be provided within frameworks that consider trauma and personal histories and ask a person what happened to them rather than what is wrong with them.
We acknowledge our responsibility to ensure that the sacrifices individuals have made for this movement become the pillars upon which we strive for positive mental health for the people of NSW.