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The reform directions presented in this document represent broad principles, and aspirations for a new approach to mental health and wellbeing in NSW.
They represent a fundamental shift – to a future in which a person, family or community sits at the heart of our thinking, services, delivery systems and planning.
That in turn presents enormous challenges to government and community-sector agencies charged with delivering not only health care but also social services, education, housing and the many other services that are critical in the lives of people who experience mental illness.
To make these changes effectively, we will need to incrementally transform the structures we have in place to deliver services – our buildings, workforce, information technology and budgets – reconfiguring them over time so that they can fulfil their primary function of supporting the things that people really need.
This section presents some initial ideas about the changes that will be required to create capable, flexible and responsive infrastructure to take us forward into a new generation of mental health reform. These will evolve, as new evidence emerges to support particular programs and approaches, as new technological developments create opportunities to do things smarter and faster, and as changing national approaches remodel the NSW mental health funding landscape.
We have barely begun to tap the potential of data collection and analysis as a means of improving our services, by giving us real-time feedback not only on the technical performance of systems of support but – crucially – on the experience of people who use them, and on whether their mental health and wellbeing improve as a consequence.
The cost of technology is falling rapidly, vastly expanding our options as we consider how to use information systems to support mental health. For example, hand-held devices that can quickly record key details at the point of contact between a service and a consumer are now becoming cheap enough to be widely deployed to mental health workers who travel to peoples’ homes. That may reduce the burden of paperwork and increase the chance that the system will hold an accurate and up-to-date record of the person’s care and concerns, leading to better quality care and treatment in future.
The continuing development of secure, internet-based technologies for data sharing and data linkage presents new possibilities for collaboration among government, the community sector, consumers, carers, families and clinicians, giving them access to information that can improve planning and help determine the best support for individuals.
Information systems can improve continuity of care between clinical care and community services and community, family and peer supports for people living with an illness in the community. With effective information sharing, there is less chance of the person living in the community inadvertently losing touch with the service system and the carers, clinician and other people in their community such as friends and relatives who can assist with recovery.
But first, people who experience mental illness must have the assurance that their privacy will be respected, and that information about them will be available only to the people and agencies that really need to know it, because they are directly involved in supporting them.
The environment in which care and support are offered is crucially important. Building design sets expectations about what will happen there; it may comfort and reassure, or it may make people feel devalued and fearful. Building location may make the difference between being able to continue work or education, and having to suspend normal life to seek care.
The evidence shows people who experience mental illness benefit from environments where families and friends feel welcomed, where they have control over their immediate environment such as lighting, and where there is artwork and windows with a view of nature. It shows also that staff experience greater job satisfaction when the built environment is more sympathetic.
We want people to be able to find support close to home, in settings that are friendly, readily accessible and that do not restrict or stigmatise them. Hospitals are and will remain essential in the most severe crisis, but the research evidence tells us we can redefine what makes a severe crisis; even when acutely unwell most people can be better supported at home or in a home-like setting.
This move from hospitals to the community requires us to rethink our current and future investment in places where we offer support. Any up-front costs will be offset in the longer term by the therapeutic benefits to people who use services.
By far the most valuable resources we hold in mental health are the skills, knowledge, energy and goodwill of the hugely diverse range of peer workers and other professionals who support people who live with mental illness.
But we still face many serious structural challenges in maintaining and developing a workforce that will carry us through the next decade, providing the diversity of support we need.
The gap we already have between demand and supply for specialist mental health staff is likely to widen in the near future as the ageing workforce retires in larger numbers and fewer people enter mental health professions. The effect will be felt unevenly; rural areas are likely to be hardest hit.
Others will leave to pursue different challenges, or in frustration with their roles or the way services are organised in a sector that can be immensely personally rewarding but also exposes workers to distress, trauma and burnout.
The avoidable loss of mental health workers is expensive in terms of recruitment, temporary replacement and training costs. Less tangible costs include reductions in morale, organisational memory and increased pressure on remaining staff.
Our existing systems emphasise the employment of people with particular professional backgrounds in particular roles. Sometimes, for no good reason, this reduces our ability to respond to local circumstances using a wider diversity of professional skills.
We know that when it comes to spending in our public health system, mental health comes a very poor second to physical health. 14% of the impact of all illnesses can be attributed to mental illness, but NSW Health spends only 8% of its budget on supporting people with mental illness. This means they do not have the same access to the high quality of care as those with physical illness.
We know that funds allocated for mental health care are not always spent on mental health care.
Hospital and health system budgets operate in such a way that money intended for mental health can be diverted to support more visible, politically sensitive issues such as emergency department waiting times or elective surgery waiting lists.
Compounding these problems, funds that are notionally allocated to community mental health may be spent in acute mental health settings, in a state which already relies too heavily on in-patient care.
Persistent under-funding leaches away the capacity of mental health services to respond to people’s needs in a timely and appropriate way.
Additional funding comes from the Commonwealth Government, via Medicare and a range of other schemes including headspace centres and the Personal Helpers and Mentors program. But these funding sources frequently do not align well with state spending priorities, meaning a person with mental health needs can fall through the gap between the two systems.