The Justice Action Team attended the second hearing on 16/10/2023, and many participants received the JA Media handout (accessible here). This is a report of the evidence in advance of the full transcript being available later.
Whilst the first hearing looked at lived experience, the second hearing focused on evidence from practitioners, community support services, and other mental health professionals. The parliamentary media release on the 12/10 (accessible here), emphasised the Committee’s interest in examining potential improvements to mental health services for both consumer and staff support, with notes and recommendations from nurses and GPs, the AAPi, the MHCC, the RANZCP, the Nurses and Midwives Association, and a number of other organisations summarised below.
Mr Graham Brereton, Registered Nurse & psychologist (Submission 83)
- Gaps exist due to perceived workload management problems as there is a lack of appropriate resources and Medicare funding for a new care coordinator role
- Currently, while there will always be some necessity, the application of ‘distant from this’ and CTO’s are overused. CTO’s are coercive. No standards for CTO’s that should be therapeutic, & is obvious ‘no brainer’ that patients should be involved in the process.
- Research shows consumers may not benefit from CTO practice, get preoccupied by it & practice makes autonomy harder.
- Specific CTO system changes recommended are:
- MHRT to ensure that members of the Mental Health Plan team are listed on the Treatment Plan, & members gets a copy (includes GP)
- Patients are to be found and to attend the MHRT hearings
- Maximise patient’s autonomy in process
Dr Tim Senior, General Practitioner (Submission 130)
- Lots of kids being diagnosed with ADHD, but GP’s find hard to find paediatricians in Campbeltown, & no process for transition >18yrs
- Calls for access to bulk billing/low cost paediatricians & GPs, & if specialist prescribes stimulants that GP should be able to continue & adjust dose.
- Regarding dual diagnosis, when Drug & Alcohol eg ICE problem, 2 weeks to detox is fast, but usually told stay on drugs while waitlisted for 3-4 mths. But can be inpatient to simultaneously detox & do rehabilitation, though bed numbers are really low. A very good option of home detox (not for high complex needs) but care coordination helps.
- ‘Assertive Care’ means GP really making self available to their patient, but GP is time/funding poor to achieve this currently
Dr Angelo Virgona, Chair of the NSW Branch of the RANZCP (Submission 139)
- Wears two hats – as a very experienced & trained psychiatrist & Mental Health Alliance member
- NSW has undermined mental health for a long time, & is Australia’s lowest spending state. Qld & Victoria made significant investment.
- Trauma is increasing and widespread, yet Psychiatrists are hindered by lack of psychotherapy skills & evidence-based therapies training (says is a training funding limitation). In public health system is a dearth of training for social problems eg Dialectical Therapy.
- As there is no significant treatment offered post admission, promote follow-up of people with borderline personality disorder with severe symptoms in NSW Health of (compassionate & evidence-based strategies for the recovery) with the University of Wollongong ‘Air’ Project. Victoria has ‘Spectrum’ & ‘Phoenix’ programs which are much better funded.
- Servicing is ‘dog’s breakfast’ -see ‘On the Brink Report’ had 3 Key recommendations in relation to it’s NSW service gaps analysis:
- Reveal NSW is so far behind it needs to catch up
- Did hotchpotch reforms that don’t consider inefficiencies & of questionable quality
- NSW & federal funding issue, where NSW has serious needs to change in order of $800mil – yet no new money in latest budget
- No NSW commitment to broader health gap analysis, let alone to reducing restrictive practices analysis
- Priorities in child/adolescent ‘Safeguards’ & in ‘HeadSpace’ (increased due to quick COVID ramp up) with more clinical psychologists. Problem of Bulk billing servicing is less attractive thus under-serviced.
- Peer & Carer workforce is needed. Workforce crisis noted in recent release of National Mental Health Workforce – shows is poor across NSW & Australia. Campbeltown got new wing – will have staffing difficulty despite new federal funding <500 psychiatrist trainees.
- Child & Youth area is underfunded & dysfunctional. Safeguards model is improving but needs it across the state.
- Psychiatrists needs skills for complex analysis ie deal with gap of ‘missing middle’ & don’t now have performing multidisciplinary teams
- No clean model of service integration. MH Funding is largely state based & driven, where Productivity Commission referred to the regional pool of PHN’s (ie federal funds 10% as reasonable at first, but less significant than local MH funding
- State LHD’s know what they are doing, but Regional Committees (local or LHD’s & primary health networks or PHN’s) are a mess. Advises test 2-3 models. Kimberley Aboriginal Services managing better for rural/remote regions with less psychologists/psychiatrists.
- GP clinical contact is 29% ie lots of time not in face-to-face care, so mainly spent on ‘risk Management’, meetings, ‘siege mentality’. GPS use to do lots of home-based treatment & also on the phone.
- Workforce problem as most psychiatrists over 55 years, and junior trainees are reluctant as see work as too stressful. Low ebb, as NSW does not keep live vacancies data, but LHD’s know. GP funding & wage issues regarding psychiatric training (Diploma MH at Monash University) & also need multidisciplinary practices. Need psychiatrists and MH nurses.
NSW Nurses and Midwives Association: Ms Helen Boardman, Registered Nurse and Clinical Consultant (Submission 146)
- Currently untenable failure to attract specialists & MH nurses need more paid leave: paid less than registered nurse but require more study (yet only 2 days leave, otherwise use RDO’s) & need speciality training eg Masters in MH Nursing to cope with higher responsibilities.
- Limitations with prescribing eg can’t continue GP prescription, limits to depot medications, & medication costs
- Collaboration with doctors limits MH nurse’s autonomy
- Take on Notice if CTO’s are being used as least restrictive practice. CTO breaches several times a week, & problem is hard to reduce one’s liberty. Lots of long term research to say CTO’s do not work in long term
- Don’t have capacity to deliver Community Mental Health Care (training & workloads).
- If permitted, can assertively support people at home.
- Extended discussion about specific mental health training for nurses (unlike specialist stream for Midwives) in Australia, and what occurs in UK. UK does offer sufficient training, and greater responsibilities of M H Nurse role . Australia is different, with has to graduate as registered nurse first, then undertake with little health department support the specialised MH training, but is remunerated less. Union view to be explored. Views MH nurse has capacity to form ‘therapeutic alliance’ with MH patients. Also could effectively engage in non-assertive team care but needs FTE of >80 – but currently is untenable as only have 1 FTE position to 135 patients. So is too big caseload issue
- The assumption to avoid the need for CTOs is for the people who have power to impose CTOs.
- About the mental health patient records, what’s needed is a response to the *situation*, not to a patient history that might be strongly influenced by antagonistic former relationships with providers. And when violence is a real risk that makes it *more* important that someone with extensive training and experience in negotiation and de-escalation leads the response, rather than a uniformed and heavily armed cop whose main profession and culture is in state authorised violence.
- It would be better served by meetings arranged at the instigation of the patient at an informal community venue with facilitation by someone with a more comprehensive ongoing relationship would be much better than funding CTO enforcers to rock up at their homes more often in the hope of better understanding their needs.
Ms Victoria Norris, Registered Nurse and Perinatal and Infant Mental Health Service Nurse Manager (Submission 146)
- NSW Health Access Line is central means of intake, to receive and triage calls, where some LHD’s can receive on call, but most LHD’s do not at night. Options are to call police or LHD’s can do Telehealth. Since COVID this triage role was privatised and transferred to Medibank . Problem is that now triage is done without background of caller (if already known to a service) and caller is no able to be put through to a staff who is known to them. If MH Team make a risk assessment, then still have option to call police.
Dr Vicki Mattiazzo, Deputy Chair of RACGP Rural Faculty (Submission 44)
- GPs are the default for MH care needs, & are central to MH system as most individuals GPs see have a mental health component – 38%. Also, GP’s are often the first contact and generate the MH Plan.
- There is a fragmentation of care, as a ‘missing middle’ for mild to moderate needs don’t get access to care. Need timely Drug & Alcohol service access, & MH is most important component.
- Experienced staff is essential for improved diagnosis & to tap into services. Access Line works well but is only a method. Problem of limited access to psychiatrists for advice, unlike the often easy and established access to other specialists (may take ½ hr but liaison is not paid for under Medicare).
- Resource barrier: if not acute, not a priority. Also if co-existing problems – eg A&D or cognitive impairment, when complex needs case – outcomes likely are person ends up in prison or dead as no-one takes responsibility. Obstacles: not get discharge or transfer summaries (if changed medication etc); need more bulk billing incentives for GP’s; is model of embedding GP’s into a CMH service, but that staff then needs good professional support/training etc.
- GP’s to do script righting [but can’t prescribe stimulants] eg ADHD, depends on Telehealth co-consulting, with psychiatrists as part of team due to complexity. GP’s need more training and time allocated, otherwise would increase risk.
- Need to act immediately as 6 mths is too long time to access to treatment programs eg amphetamines (which is increasing problem, more than alcohol). Local Hospitals are reluctant to accept people for detox, so consider Home detox programs ‘DASSI’ advice for GP’s.
- School counsellors often refer to GP to generate a M H Plan eg main problem of anxiety. However is ‘missing middle’ for those with lower acuity for acute care and are chronic. Eating disorders and self harm are great issues, but GP’s feel rushed, & don’t know what services are available thus need centralised service information
- Recently Telehealth approved for >15 mins, which rural users like but doesn’t replace face to face. Problem of poor reception if is video Telehealth item.
- Transfer the MH service to the community base. Here are several problems happened for GPs:
- GPs are probably good for well defined physical afflictions with evidence based treatment standards but not so much with mental ‘illness’.
- GPs, especially as the lack of professional distance between provider and client will better facilitate the ability of the client to direct her own treatment rather than wait expectantly for the doctor to tell her what to do after a 15 minute assessment.
- Call for the MH service in a community base; In rural areas in particular a community based service with sustained ongoing relationships with both
- -the better access to shrinks who can take the diagnostic and prescribing decisions. Call for the professional psycho-socialist to help. The access of substance detox is not relevant. The person was a junkie over 40 years ago and obviously there still were crippling delays.
- Some suggestion for the community service model–Brainstorm (need to put in practice)
- Depending on the continuing existence of CYOs, there are job positions being created.
Ms Kylie Coventry, APS Head of Policy; (Submission 143)
- Aim to strengthen support for CMH Centres, increase outreach, improve professional training, use Telehealth. Intersectionality is integral for wholistic intervention, and enable equitable access in NSW
- In prison context, proposed peer workforce as ‘navigator’ or ‘coordinator’ (as patients have limits to executive functions or self regulation, & not more pressure on families). Need to educate MH workforce on issues.
- Urges for psycho-social category & servicing to remain in NDIS (this is a response to . ABC reported in June 2023 of Federal government plan to close off further participant inclusion & funding of this category by 2026, that while says won’t remove current participants wants to ‘stop ballooning’ of scheme of 13.8% per yr, so forecast a 27,000 reduction in participant numbers, where ‘fewer people with psychosocial disability may be added to the NDIS in the future‘ if we had ‘better community mental health services’:
“We believe that if we can set up supports outside the scheme in the area of psychosocial support, maybe not everyone
needs to go on the scheme who might have otherwise gone on the scheme,” Mr Shorten told ABC Radio.
https://www.abc.net.au/news/2023-06-28/psychosocial-disability-ndis-future-inclusion/102534200) to provide what CMHC cannot. Beneficial to have support coordination & within NDIS.
- For Forensic Patients, Privacy is inadequate regarding internet and devices, also problem of cost of use
Mrs Amanda Curran, Chief Services Officer of the AAPi (Submission 35)
- Larger issue is great pressure on public health system, especially on ‘Better Access’ (from Medicare, see in Submission, February 2023 McKell report which states that the mental health emergency will persist unless out-of-pocket costs are lowered, and the workforce is increased. This includes increasing the Medicare rebate to $150 for the clients of all psychologists and allowing provisional psychologists to work under the Medicare system) ie must reduce cost to clients and improve underfunding to psychologists, & include provisional psychologists). Needs: financial incentives for training in rural/remote, cultural specific training, & to hirer diverse eg CALD staff
- Some severely unwell can be misunderstood as aggressive or non compliant thus greater benefit of lived experience/peer workforce. If highly medicated and cant get out of bed, or psychotic may need a hand to respond
- NDIS to be viable, and involved in chronic long term mental health support. Project underway to investigate the lag between inpatient discharge & transition to NDIS assistance.
- M H Services doesn’t fund interventions for youth, thus pressure on acute services. Need to increase medical rebates & sessions so at no cost for kids
- Problem of cost for Masters qualification is $35,000, with added $25,000 per annual year cost of supervision for provisional psychologists, & where capacity for paid placements is limited. So options is unpaid placement but get supervision paid for, or via Commonwealth Supported Placements [only 100 pyr offered].
Ms McGregor, Forensic Psychologist UNSW Forensic Practice (online for Submission 35)
- To deal with clinical and privacy issues in Forensic practice. Issues include: confidentiality, limited services, accommodation
- Forensic patients have multiple complex and specialised issues, but have limited services.
- DJC tensions with forensic psychologists so now considering Memorandum of Understanding
- Staff workforce: need diversity and specialisations – especially for psychology. Preponderance of clinical psychology training but Australia wide problem training is ‘vanilla’ ie anglo-saxon middle class trained that needs diversity. As APRA Supervisor trainer, views COVID impact on psychologists was devastating, & need more experienced supervisors.
- GP’s need to know of resources eg ‘Parents & Carers Group’ to support families.
Ms Sahra O’Doherty, Acting President of the AAPi (Submission 35)
- Psychologists difficulties in funding and differentiation of roles – case management, advocacy, or treatment roles.
- Those scheduled 1, do experience disruption to continuity of care, so appropriate to have a case manager as go-between (with patient consent).
- Early intervention for youth: funding is important, as are schools
- Also needs are for increased family and carers, and post natal support. Adequate Medicare funding for community support for families e.g. Headspace. If not mild to moderate classification, kids refused and not serviced but need wholistic support
- Top up the money for the funding can’t help with the quality of the psychological treatment. A deep understanding of the actual capabilities and a reassessment of psychology is needed.
Dr Evelyne Tadros, CEO of the MHCC (Submission 39)
- Peak Body for MH in NSW, supports equity & access, person-centred, wrap-around care
- Enhanced funding to NGO’s & cost savings in HASI (State wide, ‘Housing and Accommodation Support Initiative’ supports people with a severe mental illness to live and recover in the community in the way that they want to). HASI report said: admissions down by 47%; 5 x Step up/down programs are very effective but are very little about outcomes. NSW has 19 ‘Safe Havens’ showing as positive (ie staffed by peer-support workers, a non-clinical place you can go if you’re feeling distressed or suicidal thoughts – alternative to ED but no overnight stays https://www.health.nsw.gov.au/towardszerosuicides/Pages/safe-haven.aspx;. Not out-of-hours that UK model offers https://www.sabp.nhs.uk/our-services/mental-health/safe-havens). Calls for 5 + 5 yearly cycles for pilot funding.
- Next workforce survey is on 16/11/2023, with 14% of peer workers are navigators. Peer Worker Certificate 4 training plus mainly drawing on lived experience
- MHCC has a Directory of Services on its website, develops programs eg Safe Storytelling
- Prevention rather than cure to avert acute situations and CTOs.
- Peer workers require funding
- If homeless, more likely to get MH help
Ms Corinne Henderson, Principal Policy Officer of the MHCC (Submission 39)
- MHCarers NSW does support Suicide Prevention for Carers.
- Australia has very high number of CTO’s by global standards. They can be useful but not in lieu of services.
- MH Services can be too risk averse, and treatment teams if self assured when services are available, then should reduce CTOs. Some need review of safety issue and reconsider dignity of risk to see if safe and stable
- We advocate for informed decision making and have of 27 recommendations have as top 3:
- Increase HASI CLS (‘HASI Plus’ provides Community Living Supports to people who have a severe mental illness so that they can live and recover in the community, in the way that they want to.) from 2.500 to 10,000 that will require $365 mil
- Step up/down needs additional 100 positions ( ie too few, & then creates problem too intensely for Step Down). Best to also Step Up so avert hospital admissions
- Require 3-5 yrs minimum funding for Health Services. Problems of being staff driven, workforce survey says 1 in 4 is in CMH centre, & need to increase 6.5% pa
- MHCC supports need >80 CMO’s, mainly funded by PHN (some are national and some are state positions)
- Regarding integrated care: eligibility is restrictive, & care needs are for in/out of hospital plus rehab plus detox – ie combined as wholistic and trauma informed care still need progress
- Many CMO’s work as NDIS funded, but don’t have continuing funding, and this results in ‘missing middle’ for moderate & severe cases Often CMO’s are already working with people who are coping quite well in community in ‘Pathways to Community Living’. Has transitioned well for those moved into Aged Care.
- In 2020, the Productivity Commission identified are not enough increase in new services, therefore to seek additional funding.
- Await the Drug Summit that recognise the MH sector ie inter government with homeless, child/adolescent, health
- Co-commissioning with PHNs
- 70% have co-existing need and require rehabilitation, & need more integration
- Need to respect young people’s privacy
NSW Ministry of Health, Ms Deb Willcox AM (Submission 148)
- Provided $3.4 mil health care contacts to 150,000 consumers
- LHD’s and special health networks & NFP/NGO’s offer community MH and non hospital/day programs – ‘right care right place right time’
- Federal Government important, specialist medical practitioners, NDIS, PRN’s
- Integration is a priority
- 2022 National Suicide Report
- Rose Jackson noted gaps to CMH to advise the minister, with Catherine Lowrey, Alliance including Tim Heffernan, & Official Visitor Program, Justice Health, DJC, on accommodation and MH agreements
- National M H Workforce released a report 10/10/23
- YES MH Survey in 2021-2022 had 22,000, of which 78% said excellent to good, & highest domain was ‘Respect’
- ATSI & carers ratings were also 69%
- Taken on notice: MH Department’s monitoring of Workforce Vacancy Rates, but says LHD’s know
- Taken on notice: Psychiatry also has significant problems as into private not public sector, & Locums are addressed at international levels
- Lots of NFP partnerships
- Taken on notice: Audit of protocols on policy of transfer of care, collaboration & discharge summaries
- Says is highly respected expert that the department is ‘working very closely’ in consulting with Dr Virgona about ‘Gap Analysis’ – to know by end of year. While Dr wanted more detailed, is responding first to Minister questions & includes a Service Map, and expressed surprise Dr said it was ‘inferior review’.
Dr Brendan Flynn, Executive Director of the Mental Health Branch, (Submission 148)
- Acknowledged lived experience and carers
- Said NSW CMH Teams are multidisciplinary, highly trained, with high experience in care & recovery oriented
- High acuity acute care triage of this with severe or enduring MI
- Psychological services under Medicare acknowledge access to services is a problem
- Primary Care Providers often relied on
- Specific programs inequity for ATSI, CALD, LBTQi, perinatal services. Trauma overrepresented
- Zero suicide for NSW program
- CTO’s are implemented by CMO’s with set out terms for medication, psychological support, and counselling is problematic. We ask ourselves ‘What else can we do?’
- PACER – 17 police commands, mainly Metro & Central Coast, diversion technology is impressive
- Peer workers – still under development
- Regarding integration of care across MH Networks,: many PHN’s evidence based triage systems, have relatively high acuity in association of risk
- Guidelines of MH care and her levels of morbidity of physical illness too, and in collaboration with groups
- Emergency system response doesn’t go through PRN but small amount need an emergency response
- PACER is very well regarded and geography differs, so will look at other models for first responders eg Qld Police Radio Unit where police officers are advised.
- Not specifically looking at non-police first responder responses models.
Dr Michael Bowden A/Chief Psychiatrist (Submission 148)
- There is a very clear policy of transfer of care and collaboration and discharge summaries
- The gaps between consumers and government.
- Most health districts need a lot more peer workers but I bet that’s not reflected in employment ads.
- PACER isn’t a one-size-fits all solution for every community. But his iPad substitute in Hunter New England may be reducing ER admissions during crises but it sure isn’t saving lives.
- Talked about triage in terms of ‘acuity of needs’. That’s not how medical triage is supposed to work. It’s supposed to prioritise resources according to where they can be most effective
Mrs Marjorie Anderson, National Manager of 13Yarn
- Cops as first responders can extend those concerns beyond First Nations communities.
- 13Yarn is 24/7 non-clinical crisis service, based on & like LifeLine (who has 46 crisis supporters). Running for 18 mths, is culturally safe and confidential.
- Culturally safe includes not co-design but aboriginal led, and differs as ‘do with not to community response’, design from blank sheet what community wants, and should be no ‘wrong door’ & be properly funded.
- 12 mths long wait list eg ACCHOs so we do identify gaps (ACCHOs came into being because of the inability of mainstream health services to effectively engage Aboriginal communities with their services https://www.naccho.org.au/acchos/ )
- Struggled to think of a NSW service that is doing well, and sufficiently funded.
- To ‘Close the Gap’ is done differently to west, is to : work holistically with family and community, importance of confidentiality issue but must work with family and community. Kinship care is not to treat the individual, & involves resourcing the community ie treat and educate person in community, and community liaison person to know where to get supports and provide crisis care.
- Need culturally appropriate assessment tools, as wrong assessments result in problems for psychology and psychiatry who are too blinkered. Encourages see works of:
- Dr Clinton Schultz at Black Dog Institute
- Dr Marie Toombs, now at USYD, ‘I assist’ Suicide (prevention) training
- Beyond Blue 1800Respect
- Non-indigenous ignore role of family & can trigger trauma – so have to teach staff. Do lots of face-to-face in community to show are not ‘gamman’ (white ways). Focus is: connect (face to face); deescalate, empower, follow up, encourage ring back, night service, get calls inside MH Units, & general hospitals.
- NACCHOs on board so need is great, expect ACCHOS to be all to everyone (National Aboriginal Community Controlled Health Organisation (NACCHO) is the national peak body for all ACCHOs. ‘”Aboriginal health” means not just the physical well-being of an individual but refers to the social, emotional and cultural well-being of the whole Community in which each individual is able to achieve their full potential as a human being thereby bringing about the total well-being of their Community.”).
- Socio/cultural aspects operate, as 13YARN calls go down if cultural event on mob like to get together eg Community Gardens, Visitor Elder programs ie provides socio-emotional well being.
- If someone in danger, call Ambulance (care for community) not police (keep the peace) – matter of trust, results in better outcome. Need is for Ambo/paramedic teams, & not about MH training for police
- The stigmatised for marginalised groups MH challenges can learn a lot from the experiences of the indigenous community.
- The shortcoming of “individual” to refer to those seeking MH support. The whole country would be better off if we learn what ‘community means from first Nations
Mr Shane Sturgiss, CEO of the BlaQ Aboriginal Corporation
- Mainstream services are big enough to get funding then subcontract to get very small indigenous organisations to do the work for much less! However is onerous on small organisations to have to do the constant writing of grants, and reports. YARN is federally funded.
- Sometimes individuals have a sense of shame, eg if in crisis etc so sometimes other than face to face is better. Linking in is difficult as so under resourced. BlaQ was 3, now has 6 staff with no state/federal funding. ACCHOs services get little and often compete, & hard to link eg Coalition of Peaks (a representative body of over 80 aboriginal organisations/members to Closing the Gap shared decision-making https://www.coalitionofpeaks.org.au/).
- Take on notice: police alternatives consultation with community for early next year reply