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What an Emergency physician wants from Victoria’s Royal Commission on mental health

Introduction by Croakey: Many in mental health were or would have been exhausted at the news last week that a Select Committee on Mental Health and Suicide Prevention has been set up in Federal Parliament, given the truckload of reports and enquiries still awaiting action.

Committee chair Dr Fiona Martin said the emergence of COVID-19 had “changed everything”, having a significant effect on the mental health of many Australians through “increased isolation, job loss and financial stress”, though the Liberal MP doesn’t mention the likely impact on physical and mental health of the Federal Government’s decision to return JobSeeker to just above its paltry Newstart levels — under $44 a day.

Inviting submissions by 24 March, the Select Committee plans to first review the findings of the more recent of major inquiries into mental health: the Productivity Commission, National Suicide Prevention Officer, the National Mental Health Workforce Strategy and from the Royal Commission into Victoria’s Mental Health System.

“It will then turn its attention to the experiences and successes of mental health and suicide prevention stakeholders, from grassroots services through to international initiatives,” it said.

Australia’s Emergency Department clinicians have been among those urging change for years and have seen new pressures emerge in the pandemic, as former Australasian College for Emergency Medicine president Dr Simon Judkins writes below.

With Victoria’s Royal Commission finally set to hand down its pandemic-interrupted final report at a joint sitting of the state’s Parliament on Tuesday (2 March), Judkins outlines the growing crisis in mental health care and what he hopes will be in that final report.

Many Victorian mental health consumers also delivered their vision in a Declaration launched in late 2019 at the Victorian Mental Illness Awareness Council (VMIAC) biennial conference in Melbourne, which asked them to dream about a new mental health system.


Simon Judkins writes:

Two quotes stand out for me as we await the findings this week of Victoria’s Royal Commission on mental health here in Melbourne.

First the words of the state’s Mental Health Minister James Merlino:

“This is an historic opportunity for a special sitting of parliament which highlights just how important this moment is. We know that our mental health system is broken, and this report will deliver the blueprint for delivering the biggest social reform in a generation.”

Second, the words of a parent trying to access care for a child.

 “I have had to sit in the corridor of a hospital while my child is having a psychotic episode. Sometimes my child is highly agitated and highly aggressive, and we just have to wait. I am being put at risk, so is everyone else.”

In November 2018, when I was president of the Australasian College for Emergency Medicine (ACEM), we convened a National Mental Health in the Emergency Department Summit.

It was held to highlight the significant concerns that Emergency physicians had regarding the care, or lack of care, the fragmentation and under-resourcing of our mental health systems, which resulted in patients having to turn to EDs for care which should be accessible in other, better suited environments.

We  pointed to lack of  access to community care, the lack of inpatient mental health beds, and the under-resourcing in EDs across the country.

In the build-up to that meeting, ACEM had been speaking out a lot in the media, attended a lot of meetings and collected a lot of data, finding overall that our health system was failing to meet the needs of a large number of people who seek help for serious mental and behavioural conditions.

Adding to the stress and the frustration was that, once they were in an ED, many patients became stuck in a system which did not have the capacity, in both human and infrastructure resources, to provide good, appropriate care.

Long stays (measured in days), restrictive measures, people leaving the ED unseen or untreated, increasing agitation, and having many present with concurrent drug and alcohol issues led to the need for such a summit, which we co-hosted with the Royal Australian and New Zealand College of Psychiatrists (RANZCP).

Interestingly, in response to our advocacy and the combined voices of many other individuals and organisations, just a fortnight before the summit, the Andrews Government announced the Royal Commission and, in the same month, the Productivity Commission inquiry was announced.

Since then, ACEM  has released its follow-up report, titled ‘Nowhere else to go’, calling on all Australian governments to act urgently, saying emergency physicians want to work in a system that offers people safe, timely, expert and therapeutic care.

ACEM held a series of webinars across the country, with consumers, care providers, ED staff and others providing valuable inputs into what we need to see happen to improve access to care within communities, EDs and inpatient facilities.

Increasing pressure

Then COVID-19 arrived and changed everything, a little for the better and mostly for worse.

We saw an enormous effort to find housing for those who slept on the streets and moved to videoconferencing for many consultations.

We have seen changes drug and alcohol behaviours, with more alcohol consumption at home or alone in all ages, possibly contributing to increases in domestic violence.

Eating disorders, suicidality, and adolescent and young adult presentations to EDs also spiked and remain ongoing concern.

The capacity of the health system to manage the increasing presentations and need has been pushed to its limits. And of course we have seen the closing of inpatient units across our health systems due to COVID-19 outbreaks, adding enormous stress to an already stressed system, and all those who interact with that system.

As an emergency physician, I can say it has been an incredible challenge to provide the care need for all patient groups in the pandemic.

As anxieties and stressors increased, presentations of mental health issues to EDs rose, and  patients and families were forced to wait even longer for care, as the access to other services became even more limited.

We have certainly seen significant blow-out in times spent in EDs across the country with many waiting more than eight hours, and a huge number waiting days for inpatient beds.

As a result, the need for action is now greater than in 2018 when Victoria’s Royal Commission was announced.

We have seen good initiatives since 2018 and  many changes to care delivery.

Across different states, versions of safe haven cafés have popped up. In Victoria, 15 Head-to-Help clinics have been funded by the Federal Government to try fill the gap between GPs and EDs.

Nationally, new adult mental health centres are being funded in eight sites, with a view to  expand if the model is assessed to be successful in providing care where and when people need it.

There are more  outreach services, new telehealth support lines, an expansion of headspace facilities into regional areas and some redesign within some EDs to bring in dedicated infrastructure and treatment areas and improve staffing at the front door( but still much to be done). There certainly has been an enormous increase in awareness, public discourse from clinicians, carers and consumers.

But this is  only the start of what needs to be done and, when  I discuss this with my colleagues across the different states, despite all of the measures so far, the crisis feels the same.

We have seen newspaper headlines from every state regarding the increasing number of people presenting to EDs every day, record numbers of ambulances waiting for record times out the front of EDs.

In that increasingly pressured environment, we have staff who have been dealing with COVID-19 now trying to manage surge in-patient presentations and, at the same time, dealing with their own stress, fatigue and burn-out; trying to deliver compassionate care to all patients and provide an appropriate, anxiety-reducing environment…. a seemingly impossible task.

What we need

So, from where I sit, working in Emergency units in a busy city hospital and a regional facility,  I have a view of what ideal will look like and I hope this is what the Royal Commission will bring to Victoria. We need:

A system where consumers and communities have information, access and choice, so that those who require or request ongoing care and support know where that will come from and can access that care when they need.

That may be being able to access a telephone support line, a community drop-in centre (Safe Haven café model), access their outreach support worker, peer-support workers and their GP.

Many of these services will be available for extended hours, but, if they are not open 24/7, the consumer will have enough confidence in the system that they will be able to wait and access support the following day.

Outreach services (Crisis Assessment and Treatment Teams (CATT), police and mental health  teams) will be available to assess those who are having a mental health crisis in the community and manage them there and follow up with community resources.

If they require ongoing assessment, there is a choice: direct admission to a mental health inpatient facility, if that is deemed appropriate, or an assessment in an ED mental health hub with the appropriate resources, staff AND infrastructure to receive that patient and manage them in a therapeutic environment with the multi-disciplinary care that is often required.

It will be a system where mental health  short-stay units for acute, crisis care would be accessible, as well as inpatient capacity, for those whose health needs require longer periods of care. The patients would be able to have their medical and mental health needs addressed. They would NOT be discharged into homelessness.

Step-down community supports would be accessible, so when it was time, patients could be discharged from the inpatient facility to sub-acute care, possibly still in a hospital-type environment, or a Hospital in the Home (HITH) model.

In an ED, a patient presenting for care would be moved to an area, within or co-located next to the ED, which is calming and supportive. Clearly, for those who need a level of containment (and some do for their safety and the safety of others) the facilities would support less need for any physical restraint, as the design and staffing would allow for that containment and de-escalation to occur safely.

A multi-pronged approach to care would be available, with ED staff working with mental health teams, social workers, and drug and alcohol clinicians to provide a comprehensive approach, with care provided concurrently rather that in a linear pattern.

And, with the acceptance that drug and alcohol issues require a health-focused versus  justice approach, drug and alcohol related presentations would have appropriate patient care pathways; currently, the ability to admit someone into a facility which specialises in drug and alcohol issues is very limited and leaves patients, their families and staff in EDs, who try to manage these issues every day, feeling rather helpless.

And, child and adolescent care will be accessible quickly in community, rather than having to wait for months.

Patients/ consumers in regional and rural areas would not have the care determined by where they live but would have strong links into a variety of services to suit their needs, including inpatient care, community care, peer support care.

And finally, ending up in an ED, desperate for care, because there is nowhere else to go — a clear sign of system dysfunction and failure — will be a thing of the past.

In Victoria, we have been waiting for the Royal Commission’s  report to be released, so we can start the process to repair a broken system.

I suspect that every state and territory will also be looking at the report, as what troubles Victoria will not be dissimilar to what troubles them.

There is, amongst my colleagues, an eagerness to see the final report and the recommendations, but also a sense of trepidation.

We have seen many reports come and go. Change which requires all stakeholders to play a part, to responsive and accountable, is hard. But the system is in trouble; it needs resuscitation.

This is an opportunity we must grasp and ensure that we all work to a common goal, to strive for a system which supports prevention, supports individuals and families, which offers choice and access, when and where it is needed. And a system which recognises that it can and has caused harm when it should heal.

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