Chapter 1 Section C: Policy and organisational frameworks and the mental health service system
This section provides an introduction to:
- Australian mental health policy and organisational frameworks
- Public mental health care and treatment in NSW
- The National Disability Strategy Community Managed Care and Support in NSW
- Private mental health care and treatment in NSW
- Emerging, competing and complementary theoretical and practice approaches of support for people with mental health conditions
The responsibility for policy and provision of Mental Health services in Australia rests with both Commonwealth and State level tiers of government. Delivery of services is through the public, community managed and private sectors.
State and Territory governments fund not only inpatient and out-patient services, but community services that offer a range of specialist services and programs targeting people with mental health conditions and psychosocial disability, their families and carers. The Commonwealth funds a range of specialist services for persons with mental health conditions provided by private practitioners, GPs and Primary Health Networks. The Commonwealth also funds a range of community sector services and programs designed to support people with psychosocial disability and their families to live well in the community.
Following the lead of the Western Australian State government, both the Commonwealth and NSW have over the last several years established Mental Health Commissions to address reform of the mental health system. The Commissions broadly aim to create a more positive experience for persons with mental health conditions, their families and carers, and to identify the barriers that exist to their access to services, enjoyment and quality of life and social inclusion.
The Mental Health Commission of NSW is an independent body which helps drive reform that benefits people who experience mental illness and their families and carers.
The Commission is working with the community towards sustained improvement in the support offered to people who experience mental illness and in their access to employment, education, housing, justice and general healthcare.
As drivers of reform, the Commission is facilitating the implementation of a whole-of-government Strategic Plan for Mental Health in NSW which aims to support people who experience mental illness, their families and their carers to live full and rewarding lives. The Commission is also monitoring and reporting on the Strategic Plan’s implementation along with reviewing, evaluating, reporting on and advising on services and programs. The Commission’s functions also include undertaking and commissioning research and policy development, and promoting innovative programs and sharing knowledge about good practices in mental health promotion, early detection and care.
The Commission does not investigate individual complaints or penalise or sanction doctors, nurses or others. The budget for government expenditure on mental health services is not held by the Commission and it does not provide services or advice to individuals.
Find out more on the Commission website.
The NSW State Health Plan: Towards 2021 provides a strategic framework which brings together NSW Health’s existing plans, programs and policies and sets priorities across the system for the delivery of “the right care, in the right place, at the right time”. In terms of mental health, the Plan particularly identifies a whole-of government response to the NSW Mental Health Strategic Plan, which outlines strategies and directions for the provision of seamless, effective and efficient care that reflects the whole of a person’s health needs, from prevention through to end of life, across physical and mental health, in partnership with the individual, their carers and family and across public/private and Commonwealth/State boundaries.
You can read the NSW State Health Plan: Towards 2021 by following this link.
The National Mental Health Commission is an Australian Government agency that was established in January 2012. The Commission reports to the Minister for Mental Health. The Commission has a whole-of-life, whole-of-government focus – rather than just a focus on the mental health system. Its principal role is to work across Commonwealth programs, and with State and Territory mental health systems to identify ways in which mental health policy and practice might be improved in Australia. The Commission has a strong consumer and carer focus and is motivated by a concept of a ‘contributing life’ and a ‘recovery oriented approach’ for persons with mental health conditions psychosocial disability. This is described in the National Recovery Framework: Guide for Practitioners and Providers and the National Recovery Framework: Policy & Theory.
The National Mental Health Commission is not responsible for the provision or regulation of mental health services. In this sense it is independent of the mental health service system. The work of the National Mental Health Commission is overseen by 10 Mental Health Commissioners who are drawn nationally and include consumer, carer and professional experts.
The Commission’s stated strategic goals are:
- making mental health a high national priority for all governments and the community;
- providing a complete picture of what is happening and closely monitoring and evaluating change;
- promoting agreement on the best ways to encourage improvements and get better results; and analysing the gaps and barriers to achieving a contributing life, and
- promoting agreement on Australia’s direction to support for people with mental health conditions and psychosocial disability and their families and carers.
You can find out more about the National Mental Health Commission and its work by following this link.
In 2012 the Council of Australian Governments adopted a ten-year plan for mental health reform in Australia: the Roadmap for National Mental Health Reform 2012-2020. The Roadmap is based on a vision of a society that values and promotes the importance of good mental health and well-being, maximises opportunities to prevent and reduce the impact of mental health problems and supports people with mental health conditions and psychosocial disability and their families and carers to live full and rewarding lives. It is structured around six priority areas: promoting person-centred approaches to mental health care and support; improving the mental health and social and emotional well-being of all Australians; preventing mental illness; focusing on early detection and intervention; improving access to high quality services and supports; and, improving the social and economic participation of people with mental health conditions.
You can find a copy of the Roadmap by following this link.
The Fourth National Mental Health Plan was a plan adopted by all Australian Governments (Commonwealth, State and Territory), through the Council of Australian Governments (COAG). The Plan set out goals to be achieved in Australian mental health for the period 2009 to 2014. The Federal Government has committed to a Fifth National Mental Health Plan which will respond to the National Review of Mental Health Programmes and Services Report released in April 2015, conducted by the National Mental Health Commission.
You can find a copy of the Fourth National Mental Health Plan by following this link.
In 2012 the Council of Australian Government adopted the National Disability Strategy 2012-2020. The National Disability Strategy sets out a ten year policy framework for improving life for Australians with disability and their families and carers (including persons with psychosocial disability). It is based on a vision for the creation of ‘an inclusive Australian society that enables people with disability to fulfil their potential as equal citizens.’ It has six priority areas for action: building inclusive and accessible communities; rights protection, justice and legislation; economic security; personal and community support; learning and skills; and health and well-being.
You can find a copy of the implementation of the National Disability Strategy in NSW by following this link.
National Disability Insurance Agency
The National Disability Insurance Agency (NDIA) is an independent statutory agency, whose role is to implement the National Disability Insurance Scheme (NDIS), to support a better life for hundreds of thousands of Australians with a significant and permanent disability and their families and carers, this includes people with mental health conditions and psychosocial disability.
You can find out more about the National Disability Insurance Agency (NDIA) by following this link.
The National Disability Insurance Scheme
The National Disability Insurance Scheme (NDIS) is providing individualised support for eligible people with permanent and significant disability, their families and carers. The NDIS is premised on the understanding that an individual person’s needs, preferences and aspirations are different. The NDIS provides to those people assessed as eligible, a flexible, whole-of-life approach to the support needed to pursue personal goals and aspirations and participate in daily life. The NDIS provides information and referrals, links to services and activities, individualised plans and where necessary, supports over a lifetime. The NDIS has commenced in six areas across Australia, and national roll-out will continue progressively from July 2016.
You can find out more about The National Disability Insurance Scheme (NDIS) by following this link.
The Mental Health and Drug and Alcohol Office (MHDAO) is responsible for developing, managing and coordinating NSW Ministry of Health policy, strategy and program funding relating to mental health and the prevention and management of alcohol and other drug related harm. The office also supports the maintenance of the mental health legislative framework.
The Mental Health and Drug and Alcohol Office (MHDAO) was formed in 2006 by the integration of the Centre for Mental Health, the Centre for Drug and Alcohol, the Office of Drug and Alcohol Policy, and Community Drug Strategies.
The work of MHDAO is delivered through the mental health program and the drug and alcohol program, in partnership with Local Health Districts (LHDs), Justice and Forensic Mental Health, Sydney Children's Hospital Network, Non-Government Organisations, research institutions and other partner departments.
Eight local health districts cover the Sydney metropolitan region, and seven cover rural and regional NSW. In addition, two specialist networks focus on children's and paediatric services, and justice health and forensic mental health. A third network operates across the public health services provided by St Vincent's Hospital, the Sacred Heart Hospice at Darlinghurst and St Joseph’s at Auburn.
In addition to hospital inpatient and out-patient services, programs and services that can be accessed through LHDs and speciality networks include:
- Community Case Management
- Early Psychosis Program
- Mental Health Promotion, Prevention and Early Intervention
- Family and Carer Mental Health Program
- Programs and Initiatives for Children, Adolescents and Families
- Specialist Mental Health Services for Older people (SMHSOP)
- Suicide Prevention
- Youth Mental Health Services
In NSW, many services are delivered in the community by non-government organisations (NGOs). (The sector's preferred language is Community Managed Organisations (CMOs)). CMOs offer a wide range of holistic care, treatment and support programs in which the practice approach is described as ‘Recovery Oriented Practice’. Services are provided by a diverse workforce including: mental health and peer workers; social workers and case managers; volunteers; drug and alcohol and other counsellors and psychologists; and other community workers. Some CMO programs and services include other practice professionals including: psychiatrists, GPs, mental health nurses, occupational therapists, allied health and physical health specialists.
The seven core CMO mental health service types identified in the Community Managed Mental Health Sector Mapping Report include:
- Accommodation support and outreach;
- Employment and education;
- Leisure and recreation;
- Family and carer support;
- Self-help and peer support;
- Helpline and counselling services;
- Promotion, information and advocacy.
You may access some of these services through a referral from a public service or facility, a psychiatrist or GP, or a psychologist or other health professional. However, you can self-refer direct to most community managed organisations.
To find a service in the community, please follow this link to The Way Ahead directory of services in NSW
The private mental health system provides care and treatment for a range of mental health conditions. Services you can access through private providers include:
- services provided by General Practitioners (GPs);
- services provided by psychiatrists, who are doctors specialising in psychiatry, usually on referral from a GP;
- services provided by psychologists or social workers qualified in a variety of specialities, usually on referral from a GP;
- services provided by counsellors or psychotherapists trained and accredited by state and national bodies (not government), without need for a referral;
- services in private psychiatric hospitals and out-patient clinics, usually accessed with financial support from private health insurance cover and arranged by private psychiatrists and psychologists.
Generally, people experiencing a range of mental health conditions (such as anxiety disorders, depression and compulsive disorders) access help through referral from their GP to a combination of services that includes medication and/or psychotherapy from a psychiatrist and counselling or psychotherapy from a psychologist or social worker.
1C.6: Emerging, competing and complementary theoretical and practice approaches for people with mental health conditions
There are a number of competing and complementary theoretical and practice approaches for people with mental health conditions. Increasingly mental health policy and practice frameworks in Australia and internationally are reflective of trauma-informed and recovery oriented approaches and reference human rights legislation. Following are four examples of current theoretical and practice approaches:
Across the mental health system in NSW there is an increasing move towards a recovery oriented approach. Reflecting this cultural shift the concept of Recovery has more recently been embedded not only as a Principle in the National Mental Health Service Standards, and the National Mental Health Practice Standards, but is articulated in the National framework for recovery-oriented mental health services: policy and theory and the guide for practitioners and providers . What we now see is a greater acknowledgement of the importance of Recovery as a practice approach in public mental health services, although the medical model still remains the dominant approach. A reflection of this change in thinking, is for example that an amendment to the Mental Health Act 2007 (NSW) (now in force) refers to ‘Recovery’ in its objects and intentions with regards to the care and treatment of people under the Act.
Community-managed mental health organisations embrace principles of recovery in order to enhance a person’s individual recovery journey. Recovery Oriented Practice is a holistic approach to illness that addresses all aspects of a person’s life, including psychological and physical needs, as well as social, economic, education, employment, housing and other needs at the same time, whilst maximising the ability to live in the community independently. The focus is on the individual and their needs first, and on the illness, which is only one part of the person, second.‘Recovery’ is described as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life, even with the limitations caused by mental illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the challenging effects of mental illness. Recovery in a broad sense is about finding a way to get back on track after experiencing illness.
The principles of recovery on an individual level include, but are not limited to:
- Meaning, purpose and direction
- Rights and personal responsibility
- Equality and respect
- Empowerment and self-determination
- Social inclusion and connectedness
Reflecting best practice, by including every aspect of recovery in service delivery, organisations provide opportunities for participating in self-advocacy, consultation and meaningful involvement in the development of how services are run and policy is developed, and strongly support a peer workforce and consumer led activities.
Trauma-informed care and practice is an approach to mental health and human services that recognises the high prevalence of prior and ongoing trauma in the lives of people who use mental services (either voluntarily or on an involuntary basis) and who engage with a diversity of related human services. The approach also acknowledges the serious neurological, biological, psychological and social impacts of trauma of any kind on the individual.
Whilst trauma can occur as a result of a number of/or one off events, (such as an accident or natural disaster) that may cause a number of serious impacts including Post-Traumatic Stress Disorder (PTSD) the trauma particularly referred to in this context is known as ‘Complex Trauma’ - the product of overwhelming stress that is interpersonally generated.
Trauma occurring in the context of interpersonal violence, either covert or overt, often results in complex and chronic psychological and physiological injuries. Complex trauma includes the experience of violence and victimisation, including sexual, emotional and physical abuse, neglect, loss, and domestic violence including witnessing domestic violence, torture, terrorism and war. Many such experiences that occur in childhood particularly can produce intense fear and extreme stress responses in the person, as well as feelings of helplessness, hopelessness and an inability to cope.
Trauma-informed care involves mental health practitioners adopting ‘universal precautions’ to avoid triggering trauma responses and creating further trauma. It calls for the consideration (and where appropriate assessment) of symptoms concurrently with other interventions, and avoidance of interventions that are re-traumatising for example: restraint, seclusion and involuntary detention and treatment; and ensuring collaborative practice and power sharing between the practitioner and the patient/client and the individual’s personal support network; careful use of objective neutral language to describe situations; and, an understanding of the function of behaviour as a coping adaptation.
You can read more about trauma informed care and practice (TICP) by visiting another place on this website devoted to TICP by following this link.
The human rights approach is reflected in the Convention on the Rights of Persons with Disabilities (CRPD) in particular. In this respect, the CRPD is to be contrasted with earlier work on human rights and mental illness substantially based in a medical model understanding of mental health conditions and psychosocial disability.
The human rights approach emphasises respect for the inherent dignity and individual autonomy of the person, including the freedom to make one’s own choices, and the independence of persons. It also emphasises the right to full and effective participation and inclusion in society, and prohibits deprivation of liberty and segregation based on psychosocial disability.
Specifically, the human rights approach recognises the right of persons with psychosocial disability to respect for their mental and physical integrity, which includes the right to freedom from involuntary detention, restraint, seclusion and treatment with medication. The human rights approach requires that mental health care and treatment is only provided on the basis of the informed consent of the person.
The human rights approach promotes supported decision-making where required, and the eradication of all forms of substitute decision-making based upon the perceived incapacity of the person. It places major emphasis on the provision of the support and adjustments that will enable the person to make their own decisions, including in relation to their treatment, care and support.
You can read more about human rights approach to persons experiencing trauma on the website of the World Network of Users and Survivors of Psychiatry. You can read more about the application of this approach to issues affecting persons with psychosocial impairments in the work of the United Nations Committee on the Rights of Persons with Disabilities.
The social model of disability is a core element of the human rights approach which exists in stark contrast to the dominant medical model of mental illness. The social model views impairment as an ordinary part of human diversity and promotes respect for individual difference. It emphasises acceptance of difference by mainstream society rather than the treatment and cure of person with impairments so as to ‘fit in’ with a perceived norm.
The social model of disability requires adjustments to be made to enable persons with disability to participate on an equal basis with others. With respect to mental health care, treatment and support, it suggests a more active and supportive approaches rather than resort to involuntary treatment options.
You can read more about the social model of disability, including as it relates to persons with psychosocial impairment by following this link.