Conveyor belt to psychiatric ruin

By MARTIN JOHNSTON health reporter

Tom was tortured by fear when he rang to say he had not wanted to be discharged from hospital. He had been sent on his way from Taharoto, the acute psychiatric unit at North Shore Hospital, because his bed was needed for someone sicker.

Middle-aged Tom (not his real name) told the Herald he had not fully recovered from his bout of paranoia and delusions. He was not ready to be back in the community.

Yet he was well enough to see that his immediate future was likely to repeat his past: a conveyor belt of a hospital discharge, a fruitless search for somewhere suitable to live, shifting into a camping ground north of Auckland, going off his medication, becoming unwell, then back to hospital.

To break that cycle, Tom believed, he needed time in a home providing residential rehabilitation services, but he had been unable to persuade hospital staff of his need.

He said he wanted the Herald to know in advance, if he harmed himself, what lay behind it. That was months ago and in a way he eventually had his wish. He is now in the even more secure Mason Clinic, a forensic psychiatric unit.

But psychiatric nurses say many like him are discharged into the community too early to make space in overcrowded acute units since there are too few rehabilitation beds. They know these people will keep circling in and out of the system.

Appropriate housing and rehabilitation can be crucial in helping people with mental illnesses get well and providing more of it could help ease the "acute beds crisis" in Auckland, especially since there is no intention of reversing community care.

The Government has given the region an extra $2.8 million for more intensively supported rehabilitation services for community patients and a further $10 million for Auckland and Midland (Gisborne to Taranaki) to help ease national funding disparities.

The $2.8 million is intended to free space in Auckland acute units - which have about 170 beds - by creating "packages of care" for 20 patients in less-intensive situations.

The money follows a highly critical Mental Health Commission report on Auckland services last year.

The Counties Manukau District Health Board is using its share to pay a non-government organisation to provide intensive support to 10 patients in their own homes - in addition to clinical services the board already provides.

"We want to support people in the least restrictive environment ... the closest to their normal living situation," says mental health manager Ian McKenzie.

He and mental health development manager Sue Hallwright resist any suggestion that more acute beds are needed. She says other parts of the world do well with fewer per head than New Zealand, but they also have far more extensive community services.

One group which would love to get its hands on some of the new money is the Accommodation for Mental Health Society, to start Orewa's first supported home for recovering psychiatric patients.

Community Group Housing, a subsidiary of the Housing New Zealand Corporation, agreed to provide a house to let, but the Waitemata Health Board does not have the money to pay the subsidised rent and other running costs.

"When people are discharged from a hospital a lot of them have nowhere to go," says Belinda Greenwood, a board member of the accommodation society, which runs a number of homes and provides support services.

"They end up in places like camping grounds and it doesn't work because they haven't got the supported care that they need."

Supporting Families in Mental Illness, previously the Schizophrenia Fellowship, fears that there could be a "cleansing" of patients out of desirable suburbs and into poorer ones.

The group's Auckland spokesman, Mike Loveman, says this is because health authorities want to back away from paying for the accommodation for patients at lower levels of need in the community, buying only their support services. This will force them into the private rental market where many will be unable to afford higher rents.

In a survey published last year, the Ministry of Social Development tried to quantify housing problems experienced by mental health service patients. Its statistics, based partly on the 46,200 people who received services from a district health board in a three-month period, are thought to be an underestimate as some boards did not supply full figures, and they were fewer than half the number thought to be experiencing severe mental illness.

The authors estimate that:

* Up to half may have been experiencing housing difficulties, such as overcrowding, lack of personal safety, pest infestations, unaffordability, or loss of their own home because of being in hospital.

* 2000 (4 per cent) may be homeless or living in temporary and/or emergency accommodation.

* 8000 (17 per cent) may be living with a heightened risk of future homelessness (although there may be some cross-over with the housing-difficulties category).

* 20 per cent live in boarding houses and hostels long term, 6 per cent live with friends or family, 2 per cent live in hotels, motels, caravan parks or bed-and-breakfast houses, and 3 per cent are in respite care.

The report says: "The experience of poor housing, financial stress and limited social contact contributes to depression and anxiety and raises the probability of re-hospitalisation."

Officials' reports sometimes criticise boarding houses for "exploiting" mental health patients and say some houses are of poor standard, but also recognise them as a last resort for some patients and a choice for others.

A 1997 study found that 65 per cent of women in Auckland boarding houses had been pressured for sex and nearly 75 per cent felt unsafe.

Yvonne, on drugs to treat depression, considers herself lucky. She feels safe at the Mangere boarding house owned by Christine Sopp.

Ms Sopp produces a letter of registration from health authorities for her houses.

She owns five, all in South Auckland, and has 37 tenants to whom she is "mum". She has most of her tenants appoint her to receive their sickness or invalid's benefits - a practice condemned by some - and gives them about $80 a week "pocket money".

Despite the registration of her houses, Ms Sopp rues the Counties Manukau Health Board's unwillingness to buy supported accommodation from them.

Providers of contracted, supported accommodation can receive more than $1300 a week for patients assessed as having high needs - but the funding system's legality is being challenged.

Many providers are also upset that they have been forced to cope with only minimal cost-of-living price increases, despite rising costs.

One group opposed to any move to increase the number of beds in existing facilities is Mind & Body Consultants, which offers advice from a consumer perspective.

"We need to be doing things differently," says spokesman Jim Burdett. He fears that big spending on the existing system will scuttle his hopes of setting up a small home based on the American Soteria House concept, which in one version relies on staff forming strong relationships with clients rather than giving them medicines.

The fractured state of housing for mental health patients reflects a deeper malaise. It was highlighted by the commission's review for Health Minister Annette King and goes back to the big acceleration of community care to permit the cost-cutting closure of Carrington Hospital in 1992.

The review concluded that Auckland's services are fragmented and poorly co-ordinated and despite the many highly committed workers in the region, staff morale is low.

Under-funding is important and may have been worsened by fast population growth, it says, but the "systemic problems" must be fixed first. Access and discharge rules differ among the region's three health boards and there is little liaison between teams from different boards. Patients have to "repackage" their needs as they move around.

Workers, too, expressed exasperation.

"One psychiatrist commented, 'You can't look families in the eye knowing that you cannot provide what is needed - the caseload is overwhelming'."

Examining community care's introduction, the commission says it was "poorly and hurriedly executed", noting that it co-incided with the breakdown in management structures at the Auckland Area Health Board in the early-1990s.

During Carrington's closure, people were put into residential accommodation before appropriate support services were set up in the community. An audit found that $18.6 million earmarked for some community support facilities was "not ringfenced and consequently some community services never eventuated" (but the former board's mental health chief later denied this).

Another consequence of the former board's financial mess was a poorly designed acute facility, the Conolly Unit, at Auckland Hospital. The $3.8 million unit was, from soon after its 1992 opening, considered too cramped for patients and its walls too weak. It was this year replaced with a stronger, more spacious, $16.5 million unit next door.

The Waitemata board, too, wants more facilities. It is seeking Government consent to spend more than $32 million to build integrated community mental health facilities, expand one of its two acute units, and extend the Mason Clinic.

Board officials have warned that integration of the various community teams is vital to help avoid a repeat of tragedies like the 1999 Lachlan Jones murder-suicide.

One of the failings identified in Waitemata's care of Jones was the very fragmentation of services criticised in the commission's review last year.

Perversely, one cause of fragmentation is the huge growth of Waitemata's mental health services: 325 per cent, in dollar terms, in nine years.

"The result has been ad hoc facility development for community teams ... ," officials say.

Waitemata chief executive Dwayne Crombie, who acknowledges these problems, says there is also debate over whether to retain the board's wide variety of highly specialised teams, or to switch to central Auckland's largely geographically based teams.

Back in South Auckland, Sue Hallwright tries to talk down the gloom by expressing confidence the Government will inject even more money to rectify her district's woes.

"We've seen how it can work overseas. We know that with a bit more it can work here."