Mental health service planning for Aboriginal people in New South Wales

Overview

A report released by the Auditor-General for New South Wales, Margaret Crawford, has found that NSW Health is not forming effective partnerships with Aboriginal communities to plan, design and deliver appropriate mental health services. There is limited evidence that NSW Health is using the knowledge and expertise of Aboriginal communities to guide how mental health care is structured and delivered.

Executive summary

Mental illness (including substance use disorders) is the main contributor to lower life expectancy and increased mortality in the Aboriginal population of New South Wales. It contributes to a higher burden of disease and premature death at rates that are 40 per cent higher than the next highest chronic disease group, cardiovascular disease.1 

Aboriginal people have significantly higher rates of mental illness than non Aboriginal people in New South Wales. They are more likely to present at emergency departments in crisis or acute phases of mental illness than the rest of the population and are more likely to be admitted to hospital for mental health treatments.2 

In acknowledgement of the significant health disparities between Aboriginal and non Aboriginal people, NSW Health implemented the NSW Aboriginal Health Plan 2013 2023 (the Aboriginal Health Plan). The overarching message of the Aboriginal Health Plan is ‘to build respectful, trusting and effective partnerships with Aboriginal communities’ and to implement ‘integrated planning and service delivery’ with sector partners. Through the Plan, NSW Health commits to providing culturally appropriate and ‘holistic approaches to the health of Aboriginal people'.

The mental health sector is complex, involving Commonwealth, state and non government service providers. In broad terms, NSW Health has responsibility to support patients requiring higher levels of clinical support for mental illnesses, while the Commonwealth and non government organisations offer non acute care such as assessments, referrals and early intervention treatments.

The NSW Health network includes 15 Local Health Districts and the Justice Health and Forensic Mental Health Network that provide care to patients during acute and severe phases of mental illness in hospitals, prisons and community service environments. This includes care to Aboriginal patients in the community at rates that are more than four times higher than the non Aboriginal population. Community services are usually provided as follow up after acute admissions or interactions with hospital services. The environments where NSW Health delivers mental health care include:

  • hospital emergency departments, for short term assessment and referral
  • inpatient hospital care for patients in acute and sub acute phases of mental illness
  • mental health outpatient services in the community, such as support with medications
  • custodial mental health services in adult prisons and juvenile justice centres.

The NSW Government is reforming its mental health funding model to incrementally shift the balance from hospital care to enhanced community care. In 2018–19, the NSW Government committed $400 million over four years into early intervention and specialist community mental health teams.

This audit assessed the effectiveness of NSW Health’s planning and coordination of mental health services and service pathways for Aboriginal people in New South Wales. We addressed the audit objective by answering three questions: 

  1. Is NSW Health using evidence to plan and inform the availability of mental health services for Aboriginal people in New South Wales?
  2. Is NSW Health collaborating with partners to create accessible mental health service pathways for Aboriginal people?
  3. Is NSW Health collaborating with partners to ensure the appropriateness and quality of mental health services for Aboriginal people?
Conclusion

NSW Health is not meeting the objectives of the NSW Aboriginal Health Plan, to form effective partnerships with Aboriginal Community Controlled Health Services and Aboriginal communities to plan, design and deliver mental health services.

There is limited evidence that existing partnerships between NSW Health and Aboriginal communities meet its own commitment to use the ‘knowledge and expertise of the Aboriginal community (to) guide the health system at every level, including (for) the identification of key issues, the development of policy solutions, the structuring and delivery of services' 3 and the development of culturally appropriate models of mental health care.

NSW Health is planning and coordinating its resources to support Aboriginal people in acute phases of mental illness in hospital environments. However, it is not effectively planning for the supply and delivery of sufficient mental health services to assist Aboriginal patients to manage mental illness in community environments. Existing planning approaches, data and systems are insufficient to guide the $400 million investment into community mental health services announced in the 2018–19 Budget.

NSW Health is not consistently forming partnerships to ensure coordinated care for patients as they move between mental health services. There is no policy to guide this process and practices are not systematised or widespread.

In this report, the term ‘Aboriginal people’ is used to describe both Aboriginal and Torres Strait Islander peoples. The Audit Office of NSW acknowledges the diversity of traditional countries and Aboriginal language groups across the state of New South Wales.


1 Australian Burden of Disease Study: Impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011 (unaudited).
2 Australian Institute of Health and Welfare data 2016–17 (unaudited).
3 NSW Health, The Aboriginal Health Plan 2013-2023.

1. Key findings

NSW Health does not have a clear picture of the mental health service use patterns of Aboriginal people

NSW Health does not have a clear picture of the mental health service use patterns of Aboriginal people prior to them presenting at hospitals in acute phases of mental illness. Data are not sufficiently detailed to show which services Aboriginal people are accessing in the community, or whether they are accessing services before they reach crisis.

Without information about the nature and extent of Aboriginal service use patterns with preventative mental health services, NSW Health is not able to target necessary resources and treatments to assist Aboriginal patients to manage their mental illnesses and avoid crises.
Executives from 11 of 15 Local Health Districts report that mental health data and information are insufficient for their mental health service planning requirements. The main deficiency is an inability to aggregate data from Commonwealth and non-government services with NSW Health data.

New South Wales is not the only jurisdiction with limited data about the full picture of Aboriginal mental health service use in community environments. Other states and territories are similarly challenged in aggregating mental health data from multiple sources. While NSW Health has adequate data to describe its own mental health service use patterns, a lack of consistent data from Commonwealth funded services and the non-government sector, means that NSW Health’s knowledge about the service use patterns of Aboriginal patients is incomplete.

In the absence of complete data, there is limited evidence that NSW Health has taken other steps to understand the service use behaviours of Aboriginal patients in the community. For example, less than half of all Local Health Districts have developed forums to seek the views of Aboriginal stakeholders about the types of mental health services that are best suited to address the needs of local Aboriginal communities. In addition, there is no consistency in the methods that Local Health Districts use to collect information from each region.

Planning is not sufficiently targeted to ensure mental health services are available in locations where they are needed

NSW Health does not have a policy or formula to guide the distribution of mental health services across locations. Mental health services are funded by both state and Commonwealth governments and while all Local Health Districts engage in some form of joint service planning with Commonwealth providers, there is insufficient guidance or policy to ensure the equitable distribution of mental health services across geographic areas and townships. There is no oversight or service mapping to ensure that NSW Health and Commonwealth services are in the locations where they are required. 

As a result, some regional towns have limited mental health service options, while other townships have extensive service profiles. Some townships with limited service options have proportionally high Aboriginal populations. While mental health services may be available in neighbouring townships within travelling distance, transport options are limited in some regions, and the costs and time of travel can be a barrier to service access. 

NSW Health is not targeting sufficient resources to support Aboriginal mental health patients to stay well at home and avoid hospitalisation

The New South Wales mental health service profile does not include sufficient outreach services to support Aboriginal patients with complex needs to avoid crisis situations. The high numbers of Aboriginal people presenting at emergency departments in mental health crises, highlights insufficiencies in the community mental health service profile.

Aboriginal people are more likely to access emergency services in circumstances of mental health crisis than non-Aboriginal people. The statewide proportions of Aboriginal people presenting at emergency departments for mental health treatments have been increasing over time. While Aboriginal people make up just under three per cent of the New South Wales population, in 2017–18 they accounted for nearly 11 per cent of emergency department presentations for mental health reasons. In regional and rural areas, the proportions were higher at 21 per cent.

Executives from 11 of the 15 Local Health Districts and staff from all surveyed non-government organisations report a system-wide lack of mental health services with the cultural and clinical expertise to support the high numbers of Aboriginal patients requiring specialist support in community environments. 

Mental health teams in Local Health Districts lack staff numbers to meet patient demand in the community. While they have the clinical expertise to support Aboriginal people with complex mental health needs, most staffing is directed to hospital mental health services and follow-up for patients after discharge. 

A range of non-government organisations provide a significant component of the early intervention, community mental health service profile. Most are non-Aboriginal organisations receiving Commonwealth funding to deliver counselling and social supports to a predominantly non-Aboriginal clientele who voluntarily come to appointments at community mental health centres. These services offer Western counselling models of mental health care that are not widely accessed or utilised by Aboriginal people with mental illnesses.

NSW Health provides some funding to Aboriginal Community Controlled Health Services to provide mental health services. These non-government organisations have the cultural and clinical capability to support Aboriginal patients with complex mental health needs, but most advise that they lack the level of staffing and resources to meet community demand.

There is limited case coordination as patients move from one service to the next

NSW Health does not have a policy directive or protocol to identify the circumstances when a patient requires a mental health case coordinator to manage their care. NSW Health also lacks policy to identify or nominate a lead case coordinator for patients accessing multiple mental health services. Case coordination is important for Aboriginal patients requiring multidisciplinary health services to assist in the management of their mental illness, including support with medications. A case coordinator assists in the management of care and the transfer of care from one service type to another.

Case coordination and information sharing across organisations is not routine, systematised or reported in all Local Health Districts. Six of the 15 Local Health Districts have some form of system for joint case review and information sharing, while the other Districts have limited systems for communicating about patients who require or access multiple mental health services.

Mental health patients lack certainty about which agency is responsible to manage their support and care. Some mental health patients require significant assistance to access services. For example, patients with symptoms such as paranoia, poor insight into their illness, or social withdrawal can find it very difficult to access services voluntarily.

In instances where patient treatment is mandated under the Mental Health Act 2007 (NSW), responsibility for case management is clear. The Mental Health Review Tribunal or a Magistrate nominates an entity to provide medication and therapy, counselling, management, rehabilitation and other services for people subject to a Community Treatment Order. This is a legal order whereby a person must accept medication and support services while living in the community.

Case management leadership is also explicit when NSW Health manages its own Aboriginal patients as they transition from long term hospital stays to community residential care. NSW Health is the lead agency with responsibility to manage these transitions through its 'Pathways to Community Living Initiative'. Since 2015, 20 Aboriginal people have been transitioned to community residential care through this program. 

NSW Health provides limited support to assist Aboriginal people with mental illness on release from prison

Aboriginal people diagnosed with mental illness are not consistently supported by Justice Health to transition to the community with prescribed medications, a discharge summary or a referral to a mental health service after release from prison. Justice Health staff in larger prisons with more than 100 inmates have difficulty following up on patients. When inmates are released from prison without notice, usually straight from court, there is no pre-planning to support their release. In some instances, communication with Corrective Services staff is not occurring and Justice Health are not aware of pending court dates. In other instances, Justice Health staff report that they have competing work priorities and are unable to follow-up on patients after release. That said, in respect of Justice Health's role:

  • there is no key performance indicator (KPI) requiring Justice Health to report on the numbers of patients receiving discharge summaries and medications within seven days of their release
  • Justice Health has not directed resources to support the transition of adults to community mental health services post release
  • patient medical records and discharge summaries are held for two weeks at the prison where the patient was released. After the two-week period, patient records are not available to external medical agencies to ensure continuity of medications and care in the community.

NSW Health does not have an Aboriginal mental health policy to guide a complex service sector

The NSW Aboriginal Mental Health and Well Being Policy 2006-2010 expired in 2010. For almost a decade, NSW Health has operated without a directive for planning Aboriginal mental health care and integrating culturally appropriate Aboriginal models of mental health care into mainstream services.

While NSW Health has implemented policies that provide some direction for Aboriginal mental health care, none provide an overarching planning framework or a clear policy directive to address the unique needs that Aboriginal patients have for appropriate, culturally informed mental health services. Some policies advise on Aboriginal workforce planning and others contain information about partnership approaches to Aboriginal health care. They include:

  • The NSW Aboriginal Health Plan 2013-2023; to guide health partnerships between NSW Health and Aboriginal communities to ensure services are targeted to the specific requirements of Aboriginal patients.
  • The Mental Health Strategic Framework; to guide the delivery of services to all mental health patients, Aboriginal and non-Aboriginal.
  • NSW Good Health - Great Jobs: Aboriginal Workforce Strategic Framework 2016-2020.
  • The Aboriginal Health Impact Statement; requiring NSW Health Staff to report on the ways it will incorporate the health needs of Aboriginal people in the development of new and revised policies, programs and strategies.
  • Respecting the Difference: an Aboriginal Cultural Training Framework for NSW Health.

NSW Health advises that they are in the process of developing a new Aboriginal mental health policy, though there is no timeframe for its completion.

2. Recommendations

By December 2020, in partnership with Aboriginal mental health clinicians and policy experts, NSW Health should:

  1. Research, develop and publish evidence-based models of culturally appropriate Aboriginal mental health care for use in Local Health Districts.
  2. Finalise and publish an Aboriginal mental health policy framework that includes:
    • a timeline and plan for full implementation of the Framework and a communication strategy to improve the visibility and priority of Aboriginal mental health care across the mental health sector
    • methods, roles and responsibilities for collecting detailed information and data about Aboriginal service use and service demand by location 
    • a process for Local Health Districts to map services with Primary Health Networks and non-government providers to identify service gaps and duplications and plan for the equitable distribution of services across locations
    • a strategy to increase services for Aboriginal patients requiring high levels of clinical support in the community and clarification of mental health case management roles and responsibilities to ensure accountability and continuity of patient care across the different service providers and service types
    • actions to increase the numbers and types of Aboriginal workers across all levels and positions in the mental health workforce
    • new key performance indicators and performance reporting on follow-up actions that:
      • support information sharing and referrals of Aboriginal people to community-based mental health services
      • ensure follow-up actions to support mental health patients on release from prison so that they receive seven days of medication, referrals and discharge summaries.

1. Introduction

1.1 Prevalence of mental illness in Aboriginal populations

Mental illness (including substance use disorders) is the leading cause of chronic disease and the top contributor to lower life expectancy and increased mortality amongst the Aboriginal population of New South Wales. It contributes to disease burden and premature death at rates that are 40 per cent higher than the next highest chronic disease group, cardiovascular disease.4 

While Aboriginal people make up just under three per cent of the New South Wales population, in 2017–18 they accounted for nearly 11 per cent of emergency department presentations for mental health reasons. In regional and rural areas, the proportions were higher, at 21 per cent.5 

In New South Wales, Aboriginal people have higher rates of hospitalisation and premature death due to reasons of mental illness than the rest of the population. Between July 2013 and June 2015, Aboriginal people were hospitalised for mental health reasons at rates of 30 per 1,000 persons, compared with 18 per 1,000 for the non-Aboriginal population.During the years 2011 to 2015, the suicide rate of Aboriginal people was 1.4 times that of the non-Aboriginal population of New South Wales.7

Mental illness is a clinically diagnosable disorder that significantly interferes with an individual's cognitive, emotional or social abilities. Mental illness can be a lifelong condition that requires different levels of management over time. People with mental illness can have acute phases when intensive support is required, and more stable periods when less support is needed.

Common mental illnesses are anxiety and depression. Less common are illnesses where psychosis may be present such as schizophrenia and bipolar disorder. During an acute episode of psychosis, a person may experience hallucinations or delusions. Drug and alcohol addictive behaviours also fall into the category of mental illness.

Since 2013, acute hospital admissions of Aboriginal people have steadily increased for nearly all categories of mental illness diagnosis (Exhibit 1).

Exhibit 1: Acute hospital admissions of Aboriginal people in New South Wales, by diagnosis type, 2013 to 2018
Diagnosis type 2013 2014 2015 2016 2017 2018
Mood disorder 349 329 350 391 427 432
Anxiety 428 430 439 430 529 478
Injury / Overdose 161 203 177 270 247 169
Organic 26 13 11 10 18 13
Other 106 204 348 284 468 525
Personality disorder 139 156 209 267 330 365
Psychosis 925 1,030 1,278 1,434 1,552 1,440
Substance 231 259 270 296 257 278
Total 2,365 2,624 3,082 3,382 3,828 3,700

Source: NSW Ministry of Health.

Poor mental health has impacts on other health outcomes. For example, paranoia or social withdrawal can prevent people from seeking health services for other health conditions. Poor mental health can interfere with a person's ability to adhere to medication regimens. These can include medications for chronic health conditions such as diabetes and cardiovascular disease.

Mental illness in custodial environments

Aboriginal people are significantly overrepresented in prisons, constituting approximately 25 per cent of the adult prison population of New South Wales. They are more than 13 times more likely to be incarcerated than non-Aboriginal people. According to Justice Health patient surveys, 80 per cent of incarcerated Aboriginal women and 66 per cent of incarcerated Aboriginal men had been diagnosed with a mental illness in 2015, compared to 78 per cent of female and 63 per cent of male inmates in the general prison population. Diagnoses included schizophrenia, psychosis, alcohol and drug dependence, and post-traumatic stress disorder.

In 2015–16, Aboriginal young people were 24 times more likely to be in juvenile detention in New South Wales than non-Aboriginal young people. These rates have been escalating since 2009–10, when the rate of Aboriginal young people in custody was 19 times that of other young people.
Rates of mental illness amongst Aboriginal young people in custody are higher than rates of non-Aboriginal detainees. In 2015–16, 87 per cent of Aboriginal young people in juvenile detention had a diagnosed mental illness compared with 79 per cent of all other young people. Diagnoses include psychological, behavioural, attentional and substance use disorders.


4 Australian Burden of Disease Study: Impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011 (unaudited).
5 Ministry of Health data: Mental health related emergency department presentations in public hospitals 2017–18.
6 Aboriginal and Torres Strait Islander Health Performance Framework 2017 report: New South Wales (unaudited).
7 Aboriginal and Torres Strait Islander Health Performance Framework 2017 report: New South Wales (unaudited).

1.2 Responsibility for delivering mental health services

The New South Wales mental health service network

NSW Health delivers a range of mental health services in a complex sector that also includes Commonwealth and non-government mental health providers. NSW Health delivers mental health services in:

  • hospital emergency departments for short-term assessment and referral to services including inpatient hospital care
  • inpatient hospital care for patients in acute and sub-acute phases of illness
  • mental health outpatient services including medication support services, crisis or mobile assessments and outreach treatments in the community
  • custodial mental health services in adult prisons and juvenile justice centres for the general prison population
  • specialised mental health services for Justice Health patients requiring psychiatric inpatient care in forensic hospitals and other hospital care for self-harm or addictions.

NSW Health is a multi-tiered agency with the Ministry of Health (the Ministry) operating as a ‘system manager’, providing guidance, monitoring and support to a network of health services. The Ministry purchases services through service agreements with Local Health Districts and other service providers. The Ministry is responsible for developing and implementing mental health policies and collecting, collating and publishing information that informs decisions about the type and locations of mental health services across the State.

For the day to day running of mental health services and more detailed planning, the Ministry devolves responsibility to Local Health Districts. Local Health Districts are statutory corporations responsible for managing public hospitals and other health services in defined areas across New South Wales. There are eight Local Health Districts in the greater Sydney metropolitan region and seven in rural and regional New South Wales. Local Health Districts have responsibility to provide care to patients during acute phases of mental illness in hospitals and community service environments.

The Justice Health and Forensic Mental Health Network (Justice Health) is a statewide health service for adults and juveniles in custody. Justice Health provides services for over 30,000 patients annually. There are 17 psychiatry clinics providing services in approximately half of the New South Wales prisons. The remaining prisons use video conferencing to connect patients with psychiatry services.

The cost of mental health care

In 2018–19 the NSW Government Budget committed $2.1 billion to mental health services and infrastructure. This funding supports close to 60 inpatient facilities providing over 2,800 acute, non-acute and sub-acute beds across NSW Health.

NSW Government funding supports over 250 public community mental health centres. These include government and non-government mental health services, as well as those delivered as part of housing or domestic violence support. Fifty-one per cent of the centres are in metropolitan regions, 43 per cent are rural and regional, and six per cent are located within speciality networks such as Justice Health.

In New South Wales, the cost of providing specialised psychiatric units or public psychiatric hospitals was around $1.0 billion in 2016–17. This includes $750 million on acute hospital services, and $250 million on non-acute hospital services. The total expenditure on community mental health services in the same year was $561 million.

Supporting mental health patients in emergency departments and inpatient mental health facilities is significantly more expensive to the State than providing services in the community (Exhibit 2).

Exhibit 2: Average cost to New South Wales of different mental health services per person
Service Average cost per person/day
Inpatient mental health care, per patient day $1,132
Emergency department, per presentation $1,514
Community mental health care, per treatment day $243

Source: Audit Office analysis using unaudited data from the Australian Institute of Health and Welfare.

New South Wales is reforming the mental health care model from bed-based services to an enhanced community service profile. Funding is being moved to early intervention services, with $440 million committed over four years for community mental health teams and psychosocial supports.

The mental health budgeted expenditure also includes $700 million to support a statewide Mental Health Infrastructure Program. This will update existing infrastructure and build new services to respond to demand.

Since 2011–12, the NSW Government has more than doubled the annual funding for the Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS) from $12.2 million to $25.0 million in 2017–18. Subsidies for longer stay patients in not-for-profit accommodation have been increased and rural and isolated patients travelling for specialised allied health clinics are now eligible for IPTAAS travel and accommodation subsidies.

The role of Commonwealth and non-government organisations in the mental health service sector

Commonwealth funding supports non-government organisations to provide community-based mental health services. In addition, Commonwealth Medicare funding supports General Practitioners (GPs) to deliver mental health assessments, treatments and case management in primary health clinics across New South Wales. Primary health services can be the first point of access for Aboriginal people seeking mental health assessment and treatment.

Non-government organisations provide a significant component of the community-based early intervention services including psychosocial support programs.

Aboriginal Community Controlled Health Services (ACCHSs) are part of the non-government sector, receiving a mix of Commonwealth and state government funding. ACCHSs provide primary health GP services and social and emotional well-being services to Aboriginal people across New South Wales. ACCHSs deliver mental health services to Aboriginal people with complex needs. Some ACCHSs offer social and emotional support through outreach services into patient homes.

Drug and alcohol service types can be divided into two main categories in New South Wales: community therapeutic support services and residential or inpatient rehabilitation services. These services are funded and delivered by Commonwealth, state and non-government organisations. 

1.3 Standards for assessing Aboriginal mental health care

The NSW Aboriginal Health Plan 2013-2023 is NSW Health's framework to achieve improvements in Aboriginal health, ensuring services are culturally appropriate and responsive to the needs of Aboriginal communities.

The Aboriginal Health Plan requires NSW Health to form partnerships with other organisations to ensure that health services are integrated, coordinated and leading to continuity of patient care. The Aboriginal Health Plan emphasises the need for partnerships with Aboriginal people to develop culturally appropriate therapeutic environments. The strategic directions of the Aboriginal Health Plan are:

  1. building trust through partnerships
  2. implementing what works and building the evidence
  3. ensuring integrated planning and service delivery
  4. strengthening the Aboriginal workforce
  5. providing culturally safe work environments and health services
  6. strengthening performance monitoring, management and accountability.

Appropriate mental health care for Aboriginal people

Aboriginal people face significant barriers in accessing mental health services. A key factor influencing the level of access to mental health care is the cultural appropriateness of care.

Most publicly funded mental health care in New South Wales is based on Western therapeutic models. Services are short term and generally provide support during a crisis situation.

With the exception of the Aboriginal Community Controlled Health Services, the mental health sector is predominantly staffed by non-Aboriginal people. 

As part of this audit, we sought advice from Aboriginal mental health clinicians and policy makers about what constitutes appropriate mental health care for Aboriginal people. They advised that appropriate mental health care for Aboriginal people is:

  1. culturally safe, allowing Aboriginal people to draw strength from their identity, culture and community
  2. person centred and focussed on individual needs
  3. delivered by culturally competent staff with no bias
  4. holistic, trauma-informed and focussed on early intervention where possible
  5. delivered in places that are appropriate including outreach to homes and communities
  6. welcoming of the involvement of local Aboriginal community and connected to local knowledge and expertise including totems and kinship structures.

Throughout this report, assessments about the 'appropriateness' of NSW Health mental health care are based on these six principles and the strategic directions of the NSW Aboriginal Health Plan 2013-2023 that apply to appropriate Aboriginal health care at Appendix two. Section Four of this report describes appropriate care in more detail.

1.4 About this audit

The audit objective was to assess the effectiveness of NSW Health's planning and coordination of mental health services and service pathways for Aboriginal people in New South Wales.

We addressed the audit objective by answering three questions:

  1. Is NSW Health using evidence to plan and inform the availability of mental health services for Aboriginal people in New South Wales?
  2. Is NSW Health collaborating with partners to create accessible mental health service pathways for Aboriginal people?
  3. Is NSW Health collaborating with partners to ensure the appropriateness and quality of mental health services for Aboriginal people?

More information about the audit approach is at Appendix three.

2. Mental health service planning

2.1 Planning mental health services for Aboriginal people in New South Wales

The Ministry of Health (the Ministry) uses a range of data and planning tools to predict mental health service demand and estimate the mix of acute, sub-acute and community-based mental health services at a population level across the State.

The Ministry assesses population requirements for statewide hospital services and community mental health services at regional and Local Health District levels using a data analysis tool, the National Mental Health Services Planning Framework (National Framework). Embedded within the tool are formulae to match population requirements with psychosocial and clinical services.

Each Local Health District undertakes its own internal planning process to determine District-level mental health service needs. This planning process includes the development of a Clinical Services Plan that informs annual funding negotiations. Nine of the 15 Local Health Districts also utilise the National Framework to assist in planning.

Funding negotiations between the Ministry and Local Health Districts are based on assessments of population and changes in service demand patterns. Funding formulae are used to estimate expected population growth, demographics (aging, chronic disease prevalence), population estimates of Aboriginality, and scaling to increase equity across Local Health Districts. The equity adjustor is not used for mental health services but is being trialled in drug and alcohol services.

Annual funding is also allocated to support planned infrastructure developments, inter-District patient flows, NSW Health priorities and known service gaps. The Ministry assesses Local Health District funding requests, New South Wales activity data and the National Framework before approving funding allocations.

Data are not sufficiently detailed to inform service planning for Aboriginal people

NSW Health's existing data systems and tools do not provide a sufficient level of detail to identify the mental health service profile or service requirements of Aboriginal people in New South Wales.

Despite a higher burden of mental illness, NSW Health does not have a clear picture of the service use patterns of Aboriginal people prior to them presenting in emergency departments in mental health crises. NSW Health data are not sufficiently detailed to show which services Aboriginal people are accessing in the community, or whether they are accessing services before they reach crises.

Executives from 11 of 15 Local Health Districts report that existing data are insufficient for their mental health service planning requirements. The main deficiency is an inability to aggregate data from Commonwealth and non-government services with NSW Health data. NSW Health lacks the data tools that can generate system-wide information about Aboriginal service use patterns.

Similarly, the National Framework does not generate data on the mental health service trends for sub-population groups such as Aboriginal populations. Work is underway to improve the Framework through a Commonwealth funded project. This work is designed to aggregate mental health data across the different provider groups and sub-population groups, with a timeline for completion in 2021.

New South Wales is not the only jurisdiction with limited data about Aboriginal mental health service use patterns. While State governments collect their own mental health data, identifying and reporting on trends in regional or rural areas can be limited by small population numbers. Furthermore, State governments have limited control over the consistency or quality of data from other service providers including non-government organisations and Commonwealth funded services.

In the absence of complete data, there is limited evidence that NSW Health has engaged alternate strategies to understand the service use behaviours of Aboriginal patients across the State. As the central agency with responsibility to ensure appropriate statewide mental health planning, the Ministry of Health has not initiated activity to guide this process.

Of the 15 Local Health Districts, only two reported that they had forums to seek feedback on mental health service use from Aboriginal stakeholders. These Districts have Aboriginal advisory groups and surveys to assess their service population reach. However, these actions are not consistently applied across Local Health Districts, with three Districts reporting no systems at all for understanding their local Aboriginal communities’ needs.

Both quantitative and qualitative data are needed so that NSW Health can assess the nature and extent of Aboriginal interactions with preventative mental health services and target appropriate treatments to address problems before they become acute. NSW Health lacks the evidence to understand the preferred service models and options for Aboriginal patients. This lack of information limits the ability of NSW Health to provide appropriate community mental health services.

As NSW Health reforms its mental health resource model, evidence is required to target resources to the population groups and service areas where there is greatest need.

Implementing quality improvement initiatives for data collection and reporting related to Aboriginal people is a goal of the Aboriginal Health Plan. While NSW Health has undertaken some work in other health conditions, there has not been similar progress for mental health service data.

There is uneven distribution of mental health services, with duplicate services in some areas and no service in others

NSW Health does not have a policy or formula to guide the distribution of mental health services across the State. 

Mental health services are not available in all townships across New South Wales. According to most regional and rural Local Health Districts and service providers, there is an uneven distribution of mental health services in their District. Some regional townships with proportionally high Aboriginal populations have very limited access to mental health services, while other townships have duplicate services that operate in close proximity.

For example, Brewarrina is a township with over 1,650 residents. Aboriginal people make up more than 60 per cent of the population. Brewarrina has a small hospital and limited community mental health services. A visiting NSW Health clinician provides mental health services for two days each fortnight.

In the nearby town of Bourke there are over 1,900 residents and Aboriginal people constitute 37 per cent of the population. In Bourke, a NSW Health team provides community mental health services for adults, children, adolescents and the elderly. Week day services are available for people who need counselling and support for moderate and severe mental illness in community settings.

NSW Health does not have complete control over the mental health service profile in each township or region. The Commonwealth funds additional services across New South Wales. While all Local Health Districts engage in some form of joint service planning with Commonwealth Primary Health Networks, there is insufficient guidance for the equitable distribution of mental health services for Aboriginal people across New South Wales.

Most Local Health Districts have executive-level meetings to plan services with Primary Health Networks. However, in many Districts, these are informal meetings with no agenda for mental health service mapping and equitable distribution of mental health services. Executives from 9 of 15 Local Health Districts report informal or minimal Aboriginal mental health service planning.

The Fifth National Mental Health and Suicide Prevention Plan encourages state and Commonwealth health entities to work collaboratively on joint regional plans for mental health services. Some Local Health Districts are engaged in collaborative activity with Commonwealth services to develop joint regional suicide prevention plans. However, this activity is not occurring in all regions and there is no consistency in practice.

Exhibit 3: Case study on joint regional service planning

Shared investment models for mental health and drug and alcohol services

In acknowledgement of the need for a regional approach to service planning, a group of Commonwealth and State health providers have come together to work out ways to share resources.

Funding for mental health and drug and alcohol services is provided by different Commonwealth and state government departments. The distribution of these funds and resources is not always well coordinated by location. Some regions are better resourced with multiple service providers and sources of funding, while others are lacking.

The goal of this collaboration is to identify service gaps and duplications in their region and devise ways to coordinate resources so they can be distributed efficiently and effectively. Together they are mapping service availability and service funding, with the aim of developing a shared investment model that will deliver an optimal and equitable distribution of mental health and drug and alcohol services across the region.

The group is investing in economic and systems modelling tools to support evidence-based decision making and guide future funding priorities. They have held an economic modelling session with partner organisations and external collaborators to identify target outcomes, potential interventions, and areas for investment.

In 2019 they launched the North Coast Collective. The collaboration is made up of the Local Health Districts of the Mid North Coast and Northern New South Wales, along with the North Coast Primary Health Network. The Collective also plans to work with Aboriginal Community Controlled Health Services. Governance is formalised via memoranda of understanding, and work has commenced to define roles and responsibilities and decision-making processes.

Source: Audit Office research.

Significant investments in community mental health are not sufficiently targeted to patients with complex mental health needs including Aboriginal patients

The NSW Government is reforming its mental health funding model to shift the balance from hospital care to enhanced community care. In 2018–19, the NSW Government committed $400 million over four years into early intervention and specialist community mental health teams.

The NSW Government funding reforms are predominantly focussed on resourcing early intervention services that aim to prevent future decline in mental health. However, these resources are not adequately targeted to meet existing demand from Aboriginal people. Aboriginal patients require culturally appropriate, clinical services to address multidisciplinary mental health needs. Local Health Districts in metropolitan, regional and rural areas describe this gap in the service profile. The service shortcomings include:

  • a lack of support for patients requiring higher levels of clinical support to address complex mental illnesses in community settings
  • insufficient 24-hour mental health support for people facing crises overnight or during the weekend (non-emergency department services)
  • insufficient drug and alcohol support services
  • a lack of ongoing psychological services to support beyond the crisis period
  • mental health services that are not culturally appropriate.

While Local Health Districts provide care to Aboriginal patients in the community at rates that are four times higher than the non-Aboriginal population, resourcing is not at an appropriate level to meet demand. Increasing and costly presentations of Aboriginal people at emergency departments indicate the need to target resources to service profile shortcomings. These include a need for more services for patients with moderate to severe mental illness and more 24-hour mental health service options to assist people outside normal business hours.

Most non-government organisations are not funded to deliver clinical mental health services or to develop the organisational capacity to support patients with complex needs, including those in crisis or those requiring support with medications. While GPs provide clinical services in primary health clinics, their role is predominantly referral and the management of some medications. They are not funded to provide clinical outreach into patients’ homes or therapeutic support and counselling.

Aboriginal Community Controlled Health Services (ACCHSs) deliver mental health services to Aboriginal people with complex needs. Some ACCHSs offer social and emotional support through outreach services into patient homes. ACCHSs have the cultural competence and the clinical expertise to support complex cases but are not sufficiently resourced to meet the levels of demand for patients in crisis or those requiring services outside normal business hours.

In the absence of appropriate community mental health resources, Aboriginal people are accessing emergency department services in high numbers.

Key Performance Indicators influence service planning decisions

Local Health Districts offer a range of other health services along with mental health services. While Districts have discretion over their budgets, they prioritise the health services that have reporting obligations attached to performance and outcomes.

Districts are required to report annually against Key Performance Indicators (KPIs). Failure to meet targets or underperformance in these areas leads to financial penalties for Local Health Districts. Local Health Districts have 62 KPIs and 152 improvement measures across the full range of health services in each District. In order to avoid penalties, Local Health Districts prioritise resources for activity linked to KPIs. These activities include hospital services and hospital waiting times.

In the mental health service area, KPIs are attached to acute and sub-acute services; specifically, a seven day follow-up after hospital discharge, and a target to reduce unplanned readmissions within 28 days of discharge. Local Health District service agreements do not contain KPIs that drive mental health service activity beyond a month after a hospital admission. In addition, there is no KPI for community mental health services that are preventative and aimed at mitigating the need for a hospital admission such as community mental health outreach services. The lack of KPIs about community mental health care has relegated this service area in Local Health District priorities.

Limited funding to develop new therapeutic models of care for Aboriginal people

According to Local Health District executives, there is limited new funding for Aboriginal mental health services. Local Health District funding models do not have an identified stream to develop or resource Aboriginal-specific mental health services. While global health service budgets include a loading based on the proportion of Aboriginal people in each Local Health District, these funds are not tied to delivery of Aboriginal identified health care.

Local Health District executives have to weigh the costs and benefits of funding particular health options against other health priorities. Innovative approaches to Aboriginal mental health can be downstream on the priority list, when acute services such as emergency department and surgical services are competing for health funding.

Some Local Health Districts have allocated a small portion of their global budget for innovation funding. In one District, a competitive fund encourages different services to apply for funding to establish new health programs or models. However, this initiative is not specific to mental health services and applies to the widest range of health care. 

Occasionally new initiatives are block funded via a new activity funding stream, generally for a 12-month period, before being rolled into Activity Based Funding allocations in subsequent years. When new initiatives are not funded, resources must be found from global budgets.

In limited instances, the Ministry has approved short-term pilot funding for new mental health initiatives such as the Aboriginal Getting on Track in Time (Got It!) program, but these are the exception rather than the rule.

NSW Health's primary entity for developing and sharing evidence-based models of care is the Agency for Clinical Innovation. The Agency for Clinical Innovation is yet to focus on researching and developing Aboriginal models of mental health care. It is in the early stages of developing a mental health project on trauma informed care. This project is aimed at all population groups and may have some relevance for Aboriginal populations.

Long waitlists for drug and alcohol services and dual diagnosis treatments

NSW Health's planning processes have not predicted or responded to increased service demand for drug and alcohol services in New South Wales. There are significant waitlists of up to four months for publicly funded drug and alcohol rehabilitation services. Aboriginal people and non-Aboriginal people are not receiving rehabilitation and counselling services in a timely manner. National drug monitoring data shows increasing levels of drug use in New South Wales, particularly in regional areas of the State. According to close to half of Local Health Districts and service providers, there are insufficient services in metropolitan, regional and rural areas. Services for Aboriginal women and young people are particularly lacking.

Within the Ministry and a number of Local Health Districts, oversight of mental health services is separate from drug and alcohol services, preventing joint service planning and resource sharing.

Higher than average bed numbers for acute patients but lower staff ratios for community patients

New South Wales has higher than average numbers of hospital beds for people with acute mental illnesses compared to other states and territories. However, New South Wales has a lower ratio of mental health workers to support people with mental illness in the community.

New South Wales has 36.8 community mental health workers per 100,000 people. Most other Australian jurisdictions have higher numbers of community mental health workers per 100,000 people. The national average of community mental health workers per 100,000 people is 45.1. New South Wales's lower than average numbers of community mental health workers limits service availability in the community, particularly for flexible models of delivery such as outreach services and those provided outside of normal business hours.

The Ministry acknowledges the imbalance in the mental health service profile and advises that it is working to incrementally shift the service balance over time. The NSW Government's health budget reform agenda is the main mechanism to move some mental health funds from acute inpatient services to community-based models of care.

2.2 Aboriginal mental health policy

Lack of policy to guide Aboriginal mental health practice and direction

The NSW Aboriginal Mental Health and Well Being Policy 2006-2010 is now more than nine years out of date. For almost a decade, the mental health workforce has operated without a statewide policy to guide or coordinate Aboriginal mental health care.

In 2013, NSW Health implemented the NSW Aboriginal Health Plan 2013-2023. The Aboriginal Health Plan is directed to all health service areas and aims to improve Aboriginal health outcomes through partnership approaches between health practitioners and Aboriginal people. The Aboriginal Health Plan does not provide specific guidance for the planning, design and provision of mental health services.

In 2018, NSW Health implemented the NSW Strategic Framework and Workforce Plan for Mental Health 2018-2022 for the broader population. This policy guides high level governance arrangements and overarching strategic directions for the mental health system.

Other plans and frameworks provide some guidance about Aboriginal policy and workforce numbers, though none provide a comprehensive approach to Aboriginal mental health. Some of these policies include:

  • NSW Good Health – Great Jobs: Aboriginal Workforce Strategic Framework 2016-2020
  • The Aboriginal Health Impact Statement; requiring NSW Health staff to report on the ways it will incorporate the health needs of Aboriginal people in the development of new and revised policies, programs and strategies
  • Respecting the Difference: an Aboriginal Cultural Training Framework for NSW Health.

With the expiry of the NSW Aboriginal Mental Health and Well Being Policy in 2010, the mental health workforce has lacked guidance in:

  • data informed service planning so that the right mental health services are available for Aboriginal people in the locations where they are required
  • protocols for case coordination and information sharing for the continuity of Aboriginal patient care
  • evidence-based models of mental health care and assessment tools that are culturally appropriate and directed to the unique needs of Aboriginal patients.

An Aboriginal mental health clinician from one Local Health District described the lack of policy impacts on the workforce in the following terms:

There’s no overarching, strategic process that drives a plan for mental health. No advice cascading down from the executive. No formalised, coordinated approach to how we do business. No identification of what’s working where and no standardising of practice across Districts. There’s no literature review, no project plan, and no coordination. It’s not sustainable. All practice is at the whim of individual clinicians. It’s one-off, not written up and not used to provide an evidence base.

NSW Health advises that they are developing a new Aboriginal mental health policy, though there is no timeframe for its completion.

2.3 Planning mental health services for Aboriginal people in prisons

Justice Health delivers mental health services to the general population of adults and juveniles in prisons as well as specialist mental health services in forensic and prison hospitals. Justice Health receives block funding from the Ministry based on prison population data. Growth funding is based on Corrective Services projections of future bed expansions.

The Justice Health service model is based on a core staff profile at each prison, generally a small number of nurses and a GP for a few hours a week. Those prisons with infrequent access to a GP use video conferencing for doctor and specialist services.

Insufficient data to inform and plan mental health services in prisons

Justice Health does not have sufficient data to effectively plan for patient mental health needs or predict future service requirements.

Justice Health has a hybrid medical record system (electronic and paper based) which does not include electronic management of patient medications. Patient health information is recorded on multiple systems including the Justice Health electronic Health System (JHeHS), paper files, the Patient Administration System (PAS), and other databases such as the Community Health Information Management Enterprise (CHIME). 

While there are extensive individual patient files, Justice Health does not have reliable aggregate data on the mental health conditions or the medications of its patients across the New South Wales prison system. The most recent New South Wales data on patient mental health diagnoses and medications in prisons is from the Aboriginal Network Patient Health Survey conducted in 2015.

The multiple information management systems do not provide reliable information about the demand for mental health services in prisons, the needs of patient cohorts, and the broader patient medication profile across New South Wales. Justice Health is not able to aggregate patient information by frequency of patient interactions, treatment types, or prescribed medications. The limitations of patient information are further compromised by the fact that as many as 1,500 inmates per day are moved between the 39 adult prisons in New South Wales to be close to courts, or to assist with population management across the prison network.

Adults incarcerated in prisons and young people in custody do not have access to Medicare. Justice Health does not access patients' Medicare numbers or other linking information that could be used to track medical records information in the community. This impedes the ability of Justice Health to follow patient journeys or to evaluate the effectiveness of their services.

The complex and hybrid nature of this data management system seriously impedes the ability of Justice Health to share health information across the prison network and plan for current and future service demand.

More planning is required to improve wait times for health services in prisons

Wait times for health services in prisons can vary depending on the acuity of the patient and the size of the prison population. In one custodial facility, the current wait time for a mental health nurse is 88 days. In another custodial facility, the wait time is 170 days for semi-urgent mental health care. The longest reported wait time for non-urgent mental health care is over one year.

In large prisons with more than 100 inmates, wait times for non-urgent health services are generally longer than in smaller prisons, where patients are more likely to receive treatments within a matter of weeks. Justice Health policy specifies that patients with non-urgent medical needs require attention within 14 days to three months. While long wait times may not always breach policy guidelines, Justice Health staff report that long wait times are not optimum for patient health. 

At each prison, Justice Health staff record the average wait times for health services with categories based on clinical priority (urgency and acuity). This information is aggregated centrally by Justice Health, but is not used to plan staffing ratios or resource levels across the prison network.
The ratios of nurses to patients differ significantly across New South Wales prisons. Some prisons have a full-time health nurse per 30 patients while other facilities have ratios that approach one nurse per 100 patients. This unequal distribution of services creates inequity of access across the prison network.

Justice Health does not have a fixed formula to guide its staffing ratios. There is no nurse to patient ratio in prison health centres. Justice Health advises that nurse staffing is calculated on the size of the prison, the acuity of patients and rural and remoteness factors.

3. Creating mental health care pathways

3.1 Coordinating mental health services for Aboriginal people in community environments

Navigating the mental health service system is difficult for service users and service providers alike. The mental health sector has been described as 'complex and fragmented' by New South Wales parliamentary inquiries and the Productivity Commission.

It is a feature of the mental health service system that patients access a range of services for treatment and monitoring. Local health clinics and GPs provide mental health services, as do hospitals, community treatment and counselling centres. These services are provided by a mix of Commonwealth, state and non-government services.

In order to facilitate access to treatment across this complex system, service providers make referrals and share information with other providers. Mental health case coordination is required for safety purposes. Without clear oversight of patient service use, people can fall through the gaps between referrals, or medications and services can be duplicated without the knowledge of treating clinicians.

Most services share information to assist in patient care, but the system lacks coherence 

Information sharing and follow-up after mental health referral is not routine, systematised or reported across all Local Health Districts. Some Districts have extensive systems for joint case review and information sharing, while others have limited structures for sharing information about common patients across government and non-government organisations.

While the majority of government and non-government mental health providers have referral guidelines such as Transfer of Care protocols or information-sharing practices, according to 65 per cent of surveyed service providers, the current systems and guidelines are not sufficient to ensure coordinated patient care. Mental health staff advise that there is no guidance to identify or nominate a lead service provider amongst community mental health providers. Responsibility for community mental health case coordination is not always clear or known to providers or patients. With no lead organisation, patients are sometimes overlooked.

Local Health District staff in community mental health services are not required to form governance arrangements with other services for the transfer of patient care and for case coordination. In 2018, the Secretary of NSW Health wrote to all Local Health Districts to set out the expectation that they would form partnerships with Aboriginal Community Controlled Health Services to assist in coordinated health care. Despite this guidance, there continues to be inconsistent information sharing practices and limited joint case management between Local Health Districts and Aboriginal Community Controlled Health Services.

Some Aboriginal patients require high levels of support to manage their mental illness in the community. Different government and non-government service providers may be managing treatments and medications of Aboriginal patients, but governance arrangements and oversight of mental health treatment plans may be unclear to clinicians in different services.

In some regions, Local Health Districts and non-government providers have developed memoranda of understanding to guide case coordination. Others have established working groups where prescribed health bodies share information about clients accessing multiple services.

There is a risk in relying on local leadership initiatives. Working groups can be disbanded, key staff can leave services, and memoranda can become outdated. Without formalised guidelines or policy directives for case management, leadership can be diminished over time and patients can be lost to care.

Exhibit 4: Case study on coordinated care

Joint case management with an Aboriginal Medical Service

A government and a non-government provider of mental health services in South Western Sydney are working together to deliver better care coordination for patients attending both services. These services have developed a collaborative model for joint case management.

Staff from both services meet for monthly case reviews to discuss the needs of shared patients and to coordinate treatment plans and referral pathways. These meetings help clinicians to reduce duplication and ensure patients are getting the right support for their mental health, physical, and social needs.

The participating providers are the South Western Sydney Local Health District and the Tharawal Aboriginal Corporation, an Aboriginal Community Controlled Health Service in South Western Sydney.

These services also have a shared model of care. Clinicians from the District’s Community Mental Health team deliver an outreach service at the Aboriginal Medical Service, with a psychologist and psychiatrist providing assessment, review and treatment for Aboriginal clients. The Aboriginal Medical Service is a venue that provides a culturally safe environment and is a preferred location for some service users.

The two organisations maintain regular communication at all levels, from the executive staff level to frontline staff. The group have developed terms of reference to guide their responsibilities and activities, and the partnership is formalised via a Service Agreement.

Source: NSW Audit Office research.

Effective transfer of care occurs when activities are mandated or monitored

In instances where patient treatment is mandated under the Mental Health Act 2007 (NSW), responsibility for case management is clear. The Mental Health Review Tribunal or a Magistrate nominates an entity to provide medication and therapy, counselling, management, rehabilitation and other services for people subject to a Community Treatment Order. This is a legal order whereby a person must accept medication and support services while living in the community.

Local Health District staff advise that people subject to the Community Treatment Orders are receiving coordinated care.

In instances where NSW Health has attached performance reporting or Key Performance Indicators (KPIs) to activities, information sharing is occurring and there is evidence of transfer of care. For example, NSW Health entities are meeting performance targets requiring seven-day follow-ups for patients recently discharged from inpatient hospitals to care in the community.

There has been some progress in coordinating mental health and drug and alcohol care, but more is needed to shift attitudes and improve cooperation 

Some people with mental health conditions have comorbid dependencies on drugs and alcohol. In general, health services do not provide concurrent treatment for these conditions. Historically, mental health and drug and alcohol services have operated as separate entities in the Ministry and many Local Health Districts. The administrative separation of mental health and drug and alcohol services has created barriers to integrated treatment for Aboriginal patients with a dual diagnosis. A small number of Local Health Districts are making progress towards integrating drug and alcohol services with mental health care. 

NSW Health's NSW Strategic Framework and Workforce Plan for Mental Health 2018-2022 supports an integrated approach to drug and alcohol and mental health services. A goal of the framework is to align mental health with drug and alcohol services to provide comprehensive assessment and integrated treatment planning. Over the past decade, a colocation model has gone some way to coordinating mental health care with drug and alcohol services. 

NSW Health has participated in an integrated service model that combines Commonwealth funded primary health care and State funded community health care in 27 locations across New South Wales. The colocation service model of HealthOne assists in communication and coordination across health and allied health services. HealthOne NSW brings Commonwealth funded general practice and State funded primary and community health care services together. Other health and social care providers may also be involved in the HealthOne NSW model, for example pharmacists, private allied health professionals, other government agencies and non-government organisations.

While there has been some progress in integrated care models, more needs to be done across all Local Health Districts to coordinate services for people with comorbidities.

Access to Aboriginal mental health specialist programs is limited to trials in selected locations

NSW Health has partnered with Commonwealth funded services and non-government organisations to provide a limited number of specialist Aboriginal mental health programs and interventions. These programs are available in limited locations as trials or as early stage roll outs.

A tailored version of the Getting on Track In Time (Got It!) program is being trialled for Aboriginal children in one Local Health District. The mid-term review of the Aboriginal Health Plan lists this program as planned for statewide implementation, but there is no evidence that this has progressed. This early intervention program aims to help children connect with their culture and develop emotional resilience, to prevent future mental health and behavioural issues. It is targeted to Aboriginal children aged four to eight years old who display behavioural concerns and emerging conduct problems. The program is a combined care model with services offered by Child and Adolescent Mental Health Services in partnership with the Department of Education and an Aboriginal Medical Service.

Where specialised programs are shown to have positive impacts and outcomes, all efforts should be made to expand them to other sites where the benefits can be shared.

Multiple service providers create choice for clients, but in some regions, competition for clients is reducing information sharing

Confidentiality is an essential component of appropriate mental health care. In small townships where many local people are known to each other it can be difficult to maintain anonymity. Townships with multiple mental health services allow people to select one where they feel anonymous. While Aboriginal clients may prefer to access the local Aboriginal Community Controlled Health Service for most health treatments, clinicians advise that some people avoid these services when seeking treatment for mental illness. Aboriginal stakeholders report significant stigma associated with mental illnesses.

The Commonwealth and State governments have increased funding to non-government mental health service providers as part of a move towards a commissioned model of service provision and enhanced early intervention services in the community. This has led to an over-supply of services in some regional areas and under-supply in others. Government and non-government services report that some community providers compete for clients and this competition has led to poor information sharing and referral practices.

Referral pathways and information sharing is more likely to be compromised in regions where there is insufficient mental health service mapping and unbalanced mental health service profiles.

3.2 Coordinating mental health care for Aboriginal people in custodial environments

Intake processes are not providing timely access to mental health services

When a person first arrives at a custodial facility, they undergo a lengthy intake process. A Corrective Services officer completes several identification and security assessments and records any known information about an inmate's mental health. Corrective Services must advise Justice Health staff immediately if an inmate has:

  • immediate health concerns
  • drug or alcohol issues
  • a Mandatory Notification Form (MNF) in relation to self-harm or suicide
  • been detained under the Mental Health Act 2007
  • a specific court or Parole Board request for psychiatric and/or medical attention.

Justice Health staff also complete an assessment of the patient on intake and list any medications and pre-existing conditions that are disclosed during the process. In urgent cases, when the patient has symptoms of acute mental illness or significant distress, Justice Health may use video conferencing to connect with a psychiatrist or a GP for further assessment and potential medication prescriptions.

If the patient's needs are not urgent, Justice Health lists known medications on the patient's file and waitlists the patient for further assessment. Prescriptions for medications are not filled until Justice Health receives a response to their ‘Request for Information’ from external health providers. This process usually takes 24 to 48 hours but can take significantly longer, depending on the external health provider. In the case of young people in custody, timeframes are also impacted by the requirement for a parent or caregiver to consent to administer medications. Once the information arrives, the patient must wait for an available appointment with a GP or specialist before the medication can be prescribed. Interim medications or services can be provided at any stage via telephone orders to a General Practitioner.

For some patients, there can be significant delays in receiving appropriate treatments and medications for mental illness. The factors that impact on access to treatment include:

  • whether the patient disclosed medications during the intake screening process
  • information sharing with external services
  • the wait times for mental health services at the custodial facility
  • the acuity of the patient
  • patient movements around the prison network at the discretion of Corrective Services
  • access to patients in the custodial environment.

While more acute patients are likely to receive timely care, less acute patients can be waiting for a follow-up health appointment for weeks or months.

Poor access to patients exacerbates wait times for non-acute health services in prisons

Factors outside the control of Justice Health can exacerbate wait times for health services. Justice Health relies on Corrective Services staff to bring patients to health appointments. Justice Health has no authority to require that patients be brought to the health centre. Factors that can impede access to health services include security lock downs, poor communication or cooperation between Corrective Services and Justice Health staff, and the movement of inmates for security or operational reasons.

According to Justice Health staff from 75 per cent of surveyed custodial centres, the factor that is most likely to improve Aboriginal mental health care is greater access to patients.

Justice Health is working with Corrective Services to improve access to patients through benchmarking activities.

Adults with mental illnesses are unlikely to be supported on release from large prisons

On release from larger prisons with more than 100 inmates, Aboriginal people with mental illness diagnoses are not always supported to transition to the community with prescribed medications, a discharge summary or a referral to a mental health service.

According to Justice Health staff at one prison, the 'majority' of mental health patients do not receive medications on release from large prisons, including reception prisons where people are on remand and waiting to be sentenced. Staff at one prison estimated that 50 per cent of patients are released with no medications. At another prison, staff reported that as many as 90 per cent of patients are not provided with medications or discharge summary reports on release. The reasons for poor transitional support on release include:

  • some inmates are released without notice, usually straight from court and there is no pre-planning to support release
  • while Justice Health is mandated to complete patient discharge summaries, compliance is inconsistent. There is no key performance indicator (KPI) requiring Justice Health to report on numbers of patients with a discharge summary and medications within seven days of release
  • Justice Health staff have limited capacity to support the transition of adults to community mental health services and there is limited funding for this role
  • patient records are held for two weeks at the prison where the patient was released. After the two-week period, records are not always available to external medical agencies.

Justice Health does follow information sharing protocols when patients are released from prison on Community Treatment Orders.

Mental health support is available on release from small prisons and juvenile justice centres

Aboriginal adults released from smaller prisons with less than 100 inmates are supported on transition to the community with medications and discharge summaries. Even in cases where patients are released without notice, Justice Health staff are able to follow-up due to a manageable caseload.

Young people released from Juvenile Justice facilities have access to support services provided by the Community Integration Team. This is a voluntary program offering three months of support for young people as they transition to the community on release. Justice Health staff prepare post-release medications and discharge summaries and the Community Integration Team assist in connecting young people to mental health or drug and alcohol services in the community.

Exhibit 5: Case study on coordinated care

In-reach to correctional centres and post-release planning

An Aboriginal Family Health Worker on the New South Wales South Coast is providing fortnightly in-reach and holistic case management to Aboriginal women in custody. The service is available for Aboriginal women at three correctional centres in Sydney and their family members. The service is also available to women who have contact with the legal system in the community.

The Health Worker assists women to overcome challenges including access to mental health services, drug and alcohol services, family violence or housing services or any other matters where support is required. The Health Worker develops post-release plans for women approaching release and makes connections and referrals to community-based services to support women following release.

In 2017–18 the Health Worker supported over 300 women by providing referrals, advocacy and support in accessing programs, services and crisis intervention as needed. The service provides a culturally safe avenue for Aboriginal women to develop support networks to assist in the transition from prison to the community.

Since 2013, Justice Health have provided funding for this initiative to the South Coast Women’s Health and Welfare Aboriginal Corporation, Waminda. This partnership is formalised via a memorandum of understanding.

Source: NSW Audit Office research.

4. Providing appropriate mental health care

In May 2019, the Audit Office of New South Wales invited Aboriginal mental health clinicians and policy experts from government and non-government organisations to attend a one-day workshop. Workshop attendees advised on factors that improve the quality and appropriateness of mental health care for Aboriginal people in New South Wales. They described appropriate mental health care as:

  • culturally safe, allowing Aboriginal people to draw strength in their identity, culture and community
  • person centred and focussed on individual needs
  • delivered by culturally competent staff with no bias
  • holistic, trauma-informed and focussed on early intervention where possible
  • delivered in places that are appropriate including outreach to homes and communities
  • welcoming of the involvement of local Aboriginal community and connected to local knowledge and expertise including totems and kinship structures. 

The definition of 'appropriate' mental health care for Aboriginal people throughout this report is based on this advice.

Aboriginal people access emergency services at much higher rates than non-Aboriginal people

The choices that people make in relation to health service options provide some insight into the suitability and appropriateness of the service to their needs.

Aboriginal people have different mental health service use patterns than non-Aboriginal people. Aboriginal people are much more likely to be in a crisis situation before receiving mental health services, usually in an emergency department of a hospital.

Aboriginal people make up three per cent of the total New South Wales population, but they constitute 11 per cent of emergency department presentations for mental health treatments. In regional areas, Aboriginal people make up 20.5 per cent of presentations at emergency departments for mental health reasons. 

A number of factors help to explain Aboriginal mental health service usage patterns. According to government and non-government mental health organisations:

  • emergency department services are better known to Aboriginal people than other mental health services
  • community-based models of care are not appropriate for Aboriginal people
  • Aboriginal people are reluctant to access community-based mental health services to prevent crisis situations
  • community mental health services are not available for Aboriginal people after hours and during the weekend, so emergency services are the only option.

The statewide proportions of Aboriginal people presenting at emergency departments for mental health treatments has been increasing over time (Exhibit 6).

The following graph shows that while over 2016-17 to 2017-18 the number of non-Aboriginal people presenting at emergency departments for mental health treatments has decreased (28,604 to 28,038), the number of Aboriginal people continued to increase (5,744 from 5,307)
Exhibit 6: Numbers of Aboriginal and non-Aboriginal presentations at emergency departments for mental health reasons in New South Wales from 2013–14 to 2017–18
Source: Audit Office analysis of NSW Health Emergency Department data.

Partnerships with Aboriginal communities improve the appropriateness and accessibility of services

When asked about the factors that are most likely to improve the appropriateness of mental health services for Aboriginal people, the most common response from frontline service staff was 'relationships and partnerships with the local community'.

Aboriginal Community Controlled Health Services have strong links into their local communities. While some Local Health Districts have close working relationships with Aboriginal Community Controlled Health Services, partnerships are not operating in all Districts.

NSW Health has developed a partnership with the peak body for Aboriginal health in New South Wales, the Aboriginal Health and Medical Research Council. This partnership aims to achieve improvements in the health and wellbeing of Aboriginal people.

Executives from nine of 15 Local Health Districts have some form of communication or system to seek feedback from Aboriginal stakeholders. Some have committees with Aboriginal health staff, others conduct forums with Aboriginal community members. However, these forums are not always formalised, or leading to service changes. Local Health District executives identified a number of limitations to their feedback processes with Aboriginal stakeholders including:

  • the structures and models are not designed for positive engagement and generally focus on what is not working
  • the structures or relationships are not engaging a wide or diverse group of Aboriginal stakeholders
  • there is a lack of funding for evaluations.

All Local Health Districts measure service engagement using the ‘Your Experience of Service’ survey. This is a national measure of health services by consumers. It is designed to gather information about consumers' experience of care. Answers from the survey are intended to be used to build a better service experience for consumers.

Aboriginal artwork and imagery enhance hospital environments, but models of care do not reflect Aboriginal culture or practices

Local Health Districts have imagery, signage and symbols to reflect Aboriginal people and culture. Some have worked in partnership with local elders to develop design concepts for artistic works on mental health service infrastructure. These artistic representations include totems and other cultural imagery to acknowledge local Aboriginal histories and culture. In some instances, the process of developing the local art works has enhanced community knowledge about the mental health services in the region.

While visual representations of Aboriginal culture can send welcoming messages to the Aboriginal community, there is limited evidence that models of mental health care have been designed to reflect the cultural and healing requirements of Aboriginal patients. Aboriginal clinicians and policy experts describe the limitations to existing models of mental health care as:

  • not person-centred or designed to address the individual circumstances of each patient
  • not holistic or trauma informed
  • too Westernised and unobservant of Aboriginal culture
  • not cognisant of Aboriginal history and trauma.

Despite consultations with Aboriginal stakeholders, most mental health care in hospitals and the community is designed on a Western biomedical model of care.

In recognition of the need for culturally appropriate care, the Ministry recently published a training resource entitled Working with Aboriginal People: Enhancing Clinical Practice in Mental Health Care. This resource is not a policy directive. It is intended to assist clinicians to provide culturally informed care.

The New South Wales mental health workforce lacks culturally informed mental health assessment tools and models of mental health care. In instances where Aboriginal models of care have been implemented, they are a one-off initiative or a short-term trial. The case study at Exhibit 7 is one example of a healing initiative with high levels of attendance by Aboriginal people. There is no plan to expand this type of service model on an ongoing basis, or to trial other culturally informed models of mental health care for Aboriginal people.

Exhibit 7: Case study on culturally appropriate care

Culturally appropriate care: traditional healing clinics 

Several Local Health Districts have organised visits from traditional Aboriginal healing services to enhance mainstream mental health service models.

Traditional healing services provide an opportunity for patients to experience holistic healing based on Aboriginal culture and knowledge systems. These services attract a high level of engagement from Aboriginal people.

The Western NSW Local Health District has offered traditional Aboriginal healing clinics on several occasions since 2016. In early 2019 they arranged for healing services to be offered within the mental health and drug and alcohol services in Western NSW. Many participants provided positive feedback on the experience and expressed interest in attending future healing clinics.

The clinics were open to both Aboriginal and non-Aboriginal patients. All appointments were fully booked. The healers visited three services in Orange and Dubbo and saw around 60 patients.

Source: NSW Audit Office research.

Limited research into culturally informed models of Aboriginal mental health care

There is a significant gap in knowledge and evidence about culturally appropriate models of Aboriginal mental health care in New South Wales. The Ministry has not led research or development activity that would generate models of Aboriginal mental health care that are evidence based and evaluated. While there is a trial of an early childhood program in a metropolitan Local Health District and occasional funding directed to traditional healing programs, there is no overarching plan to develop an evidence base for appropriate Aboriginal mental health care.

While Local Health Districts can participate in trialling and evaluating health models, a more centralised level of research activity at the Ministry level is required to fill this knowledge gap. This includes analysis of health population data and research into existing models of mental health care for indigenous peoples nationally and internationally.

The NSW Health Population Health Research Strategy 2018-2022 aims to generate and use research and evaluation to improve health equity and the effectiveness of health interventions across New South Wales. There is no evidence of research into models of Aboriginal mental health care as part of this Strategy.

NSW Health's Agency for Clinical Innovation is not working on Aboriginal models of mental health care. While in the early stages of a mental health project on trauma informed care, there is no specific focus on Aboriginal populations.

Aboriginal staff improve mental health care but there are insufficient staff in most services

According to NSW Health executives, the factors that are most likely to improve mental health care for Aboriginal people are increases in Aboriginal staff and enhanced cultural support for service users. Frontline staff identify similar factors for improving care, in particular:

  • better coordination of services with social supports in the community
  • enhanced community engagement to reduce fear about mental health services
  • increases to Aboriginal health staff.

Aboriginal staff make up less than one per cent of the New South Wales mental health workforce. Executives at all Local Health Districts report that there are insufficient Aboriginal mental health staff in their District. According to the most recent available data from NSW Health, only three of the 15 Local Health Districts met Aboriginal workforce population targets in 2016 (Exhibit 8).

Exhibit 8: Aboriginal Mental Health Worker (AMHW) staff numbers and targets 2016
Local Health District Indigenous population estimate as at 30 June 2015 Target number
(1 AMHW / 1000 population)
Aboriginal Mental Health Workers and Clinical Leaders (including vacancies) Target met or not Percentage met (%)
Hunter New England 51,840 51.8 9 no 17.4
Western NSW 32,442 32.4 21 no 64.8
South Western Sydney 16,781 16.8 17 yes 101.2
Western Sydney 15,168 15.2 2 no 13.2
Northern NSW 14,798 14.8 6 no 40.5
Illawarra Shoalhaven 13,772 13.8 4 no 28.9
Mid North Coast 13,232 13.2 7 no 53.0
Central Coast 12,148 12.1 2 no 16.5
Murrumbidgee 12,106 12.1 13 yes 107.0
Nepean Blue Mountains 11,723 11.7 3 no 26.0
South Eastern Sydney 8,566 8.6 5 no 58.1
Southern NSW 7,461 7.5 5 no 66.7
Sydney 6,848 6.8 2 no 29.4
Far West 3,799 3.8 9 yes 236.0
Northern Sydney 3,200 3.2 3 no 93.8
Total 223,884 223.8 108    

Source: NSW Health.

NSW Health is working to increase the number of Aboriginal staff across its health workforce through targets for all Local Health Districts. The Ministry has allocated $1.0 million in ongoing enhancement for the Aboriginal mental health workforce in 2018–19, including enhancement of the Statewide Coordination Unit that oversees the development of the Aboriginal mental health workforce.

Some Local Health Districts identify positions that are exclusively available to Aboriginal applicants. There is no statewide policy or direction about Aboriginal designated 'identified positions'. Aboriginal identified positions are developed at the discretion of Local Health District executives. The numbers and types of identified positions vary from District to District.

Mental health peer workers are being employed across Local Health Districts. Peer support workers have a lived experience of mental illness and provide a non-clinical support role. There are eight positions across New South Wales and one Aboriginal identified position. A statewide mental health peer support committee does not have any identified Aboriginal members.

The Aboriginal Mental Health Worker Training Program is successful in increasing the Aboriginal workforce

As part of a strategy to enhance the Aboriginal mental health workforce, NSW Health has developed an Aboriginal Mental Health Worker Training Program. This program trains and employs Aboriginal people as mental health professionals. Since the commencement of the program in 2007, 83 Aboriginal people have graduated with the qualification. This program is enhancing the numbers of qualified Aboriginal clinicians in the mental health workforce.

Some Local Health Districts automatically transition graduates of the program into permanent employment positions. This is regardless of whether there is a mental health clinical position available. However, not all Districts offer permanency following graduation. While all graduates can continue working in Local Health Districts when they complete their traineeships, in some Districts, graduates are required to apply for jobs to secure permanent positions. Some are motivated to seek employment elsewhere if permanent employment is not guaranteed.

Partnerships with Aboriginal Community Controlled Health Services strengthen service pathways, but Aboriginal staff are under pressure

Aboriginal Community Controlled Health Services offer primary health care services to local Aboriginal communities. As community controlled organisations, their role is to respond to community requirements for holistic, comprehensive and culturally appropriate health care. They have strong links into local Aboriginal communities. Reciprocal partnerships between NSW Health providers and Aboriginal Community Controlled Health Services strengthen pathways between services and Aboriginal service users.

Aboriginal Community Controlled Health Service staff are often called upon to assist Local Health Districts and other health services to connect with Aboriginal community members. They advise that in a sector with limited Aboriginal staff, they are under pressure to provide input on all matters related to Aboriginal people, including input on matters outside of their role description.

Room to improve Aboriginal clinical feedback channels in some Local Health Districts

Local Health Districts have their own processes for seeking feedback from Aboriginal clinicians. In some Local Health Districts, Aboriginal clinicians have direct channels of communication with the Chief Executive. In others, there is limited or no direct input from Aboriginal clinicians at the executive level.

Formalised communication channels can assist chief executives to give priority to issues affecting Aboriginal mental health. Regular meetings can help to escalate issues for timely resolution and address workforce barriers and service barriers as they occur.

Appendices

Appendix one – Response from agency

Appendix two – The NSW Aboriginal Health Plan

Appendix three – About the audit

Appendix four – Performance auditing

 

Parliamentary Reference: Report number #326 - released 29 August 2019

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Acknowledgements

Banner image: ‘Bloomfield Hospital Moasic’, The mosaic reproduced on the report cover is the result of a collaborative project between Aboriginal artists, Aboriginal elders and community members along with staff and patients at the acute inpatient unit at Bloomfield Hospital in Orange NSW. The mosaic represents the social and emotional journey of hospital inpatients. The principal mosaic designer is Aboriginal artist, Alicia Lonsdale. Catherine Bennet is the principal mosaic artist. The inpatient unit is named Amaroo, which in Aboriginal language means ‘beautiful place’. Permitted for use by NSW Health under Creative Commons Attribution-ShareAlike 3.0 Unported Licence.