Mental breakdowns don’t happen overnight. Human beings are intrinsically resilient and it usually takes multiple forces operating over a sustained period to overwhelm us with emotional pain and compromise our ability to function. There are nearly always warning signs, which are often ignored.
The same is true of health and other government systems. The present Victorian Government in late 2016 acknowledged that Victoria’s mental health system had reached the point of a breakdown. A breakdown is costly and it takes time to recover, but also represents a chance to create a better future.
Twenty years ago Victoria was the envy of Australia and the world, with an innovative new mental health system that had swept away the 19th century asylums, built new inpatient units in acute hospitals, had begun to build a dynamic community mental health system and pioneered early intervention for psychotic illness. With the promise of further growth and investment the future for Victorians with mental illness and their families looked genuinely hopeful. This promise was broken. Toxic complacency and neglect set in, with a slow dismantling of the assertive community mental health system and a corresponding retreat into emergency departments. This dismantling, combined with major population growth – more than half a million people since 2011 – has created a perfect storm. Increasing numbers of people with mental illness are consigned to the streets, to prison or the morgue at immeasurable human and financial cost.
Victoria has slipped from the highest funder per capita for mental health in Australia to the lowest. Compared to the national average, Victoria covers half as many people, a mere 1 per cent of the Victorian population, for their mental illness needs, with greatly reduced community mental health care and fewer beds. The target should be 3 per cent, reflecting the proportion of the population who experience serious mental illness every year and who should expect access. Victoria’s mental health system is turning away around two-thirds of those who need expert care.
In our own service, Orygen, which is meant to cover more than one million people in Melbourne’s west, three out of four young people with serious mental illness are turned away each year because we don’t have the people, money or facilities to support them. Access to care is only possible in desperate circumstances, typically via emergency departments, often involving police and/or ambulance, and even then this is limited to crude risk management and of short duration. Access typically requires violent or suicidal behaviour rather than preventing it. Inevitably preventable deaths and incarceration rates have increased substantially.
Public mental health staff have been forced into survival mode. Unable to deliver expert care they are increasingly demoralised as they witness the weekly death toll, and are unfairly blamed by the media and relatives for something that is largely beyond their control. High-quality clinical expertise, public or private, is increasingly hard to find in our prosperous society. If this were happening in any other area of health care, e.g. cancer or heart disease, there would be a public scandal, and it would be immediately addressed.
In the wake of the “Targeting Zero” report on hospital safety by Stephen Duckett in 2016, the current Victorian government has found the courage to openly acknowledge that the system has broken down, and the consequent threats to the health and safety of the Victorian public. The only question now is, will the Victorian government invest promptly, decisively and strongly enough in a fully redesigned system scaled up to respond to the unmet need?
We can no longer accept the confetti and band-aids of the past 20 years. This is well beyond “awareness” and “conversations”, which, in giving the impression that the issue is being addressed, are now a distraction, even a barrier, rather than an enabler. What we need is a radical redesign, as well as major and rapid investment, to turn around 20 years of decline.
Too many Victorians are currently being let down by our fraying mental health system, unable to access the assertive and responsive community mental health care they need and deserve. Their untreated conditions are currently escalating in severity and impact until they present to an emergency department at a point of crisis. This situation must be addressed.
Professor Patrick McGorry is the Executive Director of Orygen, The National Centre of Excellence in Youth Mental Health; and Professor of Youth Mental Health at The University of Melbourne. This is an extract from the Redmond Barry lecture he will give tonight at the State Library of Victoria.
This piece was first seen on ‘The Sydney Morning Herald’ 29 November 2017.