The Royal Commission’s Interim Report: Targeted acute mental health service expansion – Recommendation 2
The Royal Commission recommends that the Victorian Government, through the Victorian Health and Human Services Building Authority and the Mental Health Implementation Office, provides funding for 170 additional youth and adult acute mental health beds to help address critical demand pressures. The allocation should be as follows:
- 135 additional acute inpatient public mental health beds or equivalent beds, with the majority of these delivered by the end of 2021 and the remainder by mid-2022, proportionally provided to Barwon Health and to Melbourne Health, the latter in alliance with Western Health and Northern Health, using the following criteria: predicted population growth, forecast bed availability, socio-economic need and the availability of primary and community-based health services
- 35 additional acute inpatient mental health beds or equivalent beds procured by the end of 2021 from a private provider to deliver clinical treatment, care and support for public patients who would otherwise be treated in a public inpatient mental health unit.
The design and establishment of the additional beds should:
- be contemporary, co-designed with people with lived experience, and provide high-quality care in a hospital setting
- involve public, private and community health service partnerships.
Assertive outreach should be used to enable acute care in a home or community residence, where possible, as a direct substitute for an inpatient bed.
The recommendation of an increase of 170 acute beds across the state was seen by VMIAC as a contentious issue, with members perceiving the current state of inpatient care to be inadequate at its best, and harmful at its worst.
Considering this, VMIAC sought responses from consumers about processes and models of care that need to be embedded into the implementation of these beds to ensure that those in crisis are better supported – namely, what is needed in the acute system to move it from a holding space into a healing space.
The overall feedback was that, if they are going to exist, the new acute beds will need to:
- Champion consumer agency and choice
- Be less clinical and more welcoming
- Eradicate involuntary treatment
- Ensure that consumers feel safe
- Be staffed by lived experience workers
- Provide consumers with person-centred and holistic care
- Ensure gender safety and gender appropriate healing.
Champion Consumer Agency and Choice
Consumers will have greater agency in their treatment, especially regarding duration of stay and their preferred clinical staff. Participants also expressed a strong desire for the eradication of involuntary treatments.
“…greater agency for consumers in their own treatment, greater freedom for consumers to choose which team members they do and don’t work with. Being able to have control over this can improve the quality of someone’s stay”
There was strong agreement that consumers will have greater access to information regarding their choices, suggesting that the beds be co-managed by a variety of specialists so that “a range of viewpoints and treatments are available.” One consumer suggested having more posters/signage about Independent Mental Health Advocacy (IMHA) the Mental Health Legal Centre (MHLC) in wards to help ensure that consumers have greater access to information about their rights and the choices available to them.
What ‘choice’ looked and felt like for consumers, accessing these beds was explored, with many participants focusing on key areas of access, preferred treatment options and freedom. An acute model that allows for consumers to make choices for themselves will:
“…support for a person’s own narrative, understanding, autonomy, diversity and choices, with support to tailor make programs to the person’s design”
“… be where people can freely come and go”.
“…consider consumer wishes on how their admission could best help them, not harm them!”
“…ensure there are (lots of)… lived experience consumer peer support workers, as well as independent mental health advocates, social workers and access to legal aid and other reps etc. who ensure that patients’ primary ‘rights’ are upheld.”
Less Clinical and More Welcoming
The aesthetics of the environments in which acute care is delivered was a key discussion point across the consultations, with the ‘clinical’ and ‘cold’ nature of current acute settings seen as particularly problematic. Improvements that make the space more welcoming and home-like included natural lighting, views of (and access to) gardens and outside space, and comfortable furnishings.
A number of participants suggested that the PARC model or an entirely new model that replicated the ‘welcoming’ aspects of PARC facilities (e.g. private rooms, ability to come and go, amenities that the consumer would have at home) would be best for the new acute beds. Additionally, there was strong support for these beds to be placed in the community via a hospital in the home model.
In a follow-up survey on this topic, consumers were asked how they would feel about the new acute beds if they were implemented in a new model outside the hospital system. The below results demonstrate that it is extremely vital that any new acute beds are outside the current system with more consumer choice. This is a critical issue for the implementation of this recommendation.
Question: 170 new acute beds will be brought into the mental health system. You told us that you did not want them in the current system, and they need to be in a new supportive model outside the hospital system. How important is this new model for acute beds?
Be safe for consumers
Safety and security were paramount in discussions for participants – a person in an acute stage of distress should never feel at risk of harm when in the care of the public health system.
Most participants wanted the beds to include secure, private rooms and additional safe spaces. These safe spaces should be relevant to the needs of women, LGBTQIA+, CALD and First Nations consumers.
“It is vital to make sure that these spaces are safe for gender diverse and CALD consumers.”
Staffed by lived experience workers
There was a clear request for lived experience peer workers to be located in the proposed acute settings; participants suggesting that having someone who “knows what it’s like” is important to recovery and overall feelings of safety. There was also a concerted push for the voice of lived experience to be embedded in the development and management of the beds with many participants commenting in favour of this:
“They need to ensure there are (lots of) representatives from the lived experience consumer peer support workers, as well as independent mental health advocates, social workers and access to legal aid and other reps etc who ensure that patients primary ‘rights’ are uphold.”
“Obviously, if we have to have them [acute beds], they should be developed using a consumer-survivor-led co-production process and they should be consumer-survivor- managed and consumer-survivor-staffed.”
“Jointly managed by consumers, psychiatrists, psychologists, social workers etc so that a range of viewpoints and treatments is available.”
“They should be managed by regional health facilities and staff should include people with lived experience of MH and people of all ages. They should also include female staff for female patients as required and CALD appropriate staff as required.”
“The focus should be on embedding the experience of survivors of the medical model who can use their own journey of healing and recovery to support and assist people in distress, despair and suicidality.”
Person-centred and holistic care
Survey respondents were clear that there was a need for the new acute service to have empathetic, person-centred and trauma-informed approaches to care:
“[The beds] should be staffed by persons who will respect full rights and safeguard them and who are open to and understand a huge range of different perspectives”.
There was a strong desire for the model of the new acute beds to “consider the social determinants of health” and be holistic in its treatment options; the most common suggestions of holistic services being art therapy and music therapy.
Gender sensitivity and responsiveness
Gender emerged as an issue to be considered in the initial VMIAC consultations with many workshop participants speaking about their experiences in inpatient units where gender was not considered. This led to further exploration of this in an additional consultation, asking a specific question on whether the new beds should be separated by gender. Sixty percent of these respondents believed this was very important:
Question: Should the additional beds be arranged by gender?
Additional comments supporting the need for gender safe spaces:
“Women need to be and feel safe when they are in a mental health facility and probably feeling fragile.”
“Yes, as requested and required by the patients”
“I’m NOT going in a locked ward or even an unlocked ward with aggressive men. As a DV survivor, how would that help me?”
It has been noted that the abuses women face within the Victorian mental health system caused by the links between general gender discrimination in society and the abuses of mental health consumer Issues. Women are more likely to be abused by other consumers in wards and also by staff. This has been identified most recently through reports such as the Mental Health Complaints Commission’s Right to Be Safe Report.
If gender safety is going to be guaranteed, there will need to be single gender wards or rooms with locks. It was also noted that staff need specialist training about gender and cultural appropriate approaches as well as training about LGBTQI+.