Mental health's revolving door

By MARTIN JOHNSTON

When Rosie was taken to a rest-home - mentally unwell and with memories of psychiatrists, nurses, a judge - she would have been expecting a bit of peace and quiet.

Forty-eight hours earlier, the judge had released her from compulsory assessment and treatment under the Mental Health Act and now she was at the rest-home for, well, a rest. It's called "respite".

Tiaho Mai, the 50-bed acute mental health unit at Middlemore Hospital, was full. That's normal.

But respite failed for Rosie (not her real name), who is in her late 20s. After she became paranoid and irritable, crisis team nurses came to take her back to the acute unit.

It was a routine job, but while they were arranging the transfer, it was as if all the pent-up problems of Auckland's overloaded, under-staffed, fragmented mental health system burst upon the rest-home.

Within 45 minutes, two other psychiatric respite patients lost control. One, who had been at the rest-home for about five days, attacked a respite nurse, trying to gouge her eyes.

While psychiatric nurses were bringing her under control, readying her for transfer to Tiaho Mai, a third patient attacked an elderly man, a permanent resident of the rest-home. His face was split open.

At least three police cars came to the rest-home. The last patient was taken to the police cells; the other two were transferred to Tiaho Mai.

"Remember, there are no spare beds there," says Alan Gundesen, a crisis team nurse for the Counties Manukau District Health Board and union delegate.

"We arrived at Tiaho Mai, two patients under the Mental Health Act, no beds," he says, recalling the incident from last year.

"So they did what I would call unhealthy discharges, discharging people before their time. Risky discharges, into respite.

"I couldn't believe it," Gundesen says. "Does this give you an idea of the madness of it? This is psychiatry. It doesn't make sense. It's insane."

A community psychiatric nurse for 20 years, he says this revolving door of hospital and respite care has developed only in the last few years as the acute units have become constantly full, and is highly risky for patients, staff and the public.

The Auckland region has about 170 beds in four acute units based near Auckland, North Shore, Waitakere and Middlemore Hospitals. Because many people cannot obtain the community-based care they need when serious mental illness flares up, they become sicker and are admitted to an acute unit.

The promoters of community care say this needless stress could be avoided if there were more community services. The Public Service Association has pushed for more "step-down" or "sub-acute" beds, which delegates say would reduce pressure on the acute units.

To outside observers, Auckland's mental health services appear to have been in an almost perpetual crisis since the cost-cutting closure of Carrington Hospital in 1992 and even before. The concept of community care, implemented gradually since the 1970s but accelerated in the 1990s, remains controversial.

High-profile killings by psychiatric patients, like Lachlan Jones, Mark Burton and Paul Ellis, fuel a widely held belief that it has not worked - even though young men, as a population, pose a greater risk of violence than people with mental illness.

Most in the mental health sector want only to expand community care, not contract it.

The so-called acute-beds crisis, highlighted by the PSA's campaign of mini-strikes, forced Health Minister Annette King last year to call for a review of Auckland's mental health services.

The strikes by acute unit and community workers were designed to force their employers, the Waitemata and Counties Manukau Health Boards - and by proxy the Government - to fix the problems fast.

Frequently, with no spare beds at acute units in the upper North Island, mentally disturbed patients have been locked in police cells, sometimes for two or three days. Others have been forced to bed down on mattresses in the acute units' interview rooms, discharged prematurely, or sent to general hospitals not designed to cater for them.

More patients assault staff.

Nurses, unable to keep in the acute units patients who they believe need to be there, worry about when the next tragedy will occur.

Tragedies like the Lachlan Jones murder-suicide are devastating not only for the families, but also for staff. Such cases and the general stress have led to a "phenomenal turnover" of staff.

"I have been in my 14-member team for 18 months and there are three people who were there when I started,"says Martina Allen, a PSA delegate. "Most people have been replaced several times."

Since being interviewed, she has returned to working in an acute unit because the community work was "professionally risky" in the extreme. She was caring for 50 patients (ideally it should have been 35, although ratios are improving).

Annette King accepted the recommendations of the Mental Health Commission made after its Auckland review, and announced a mental health funding boost of $12.8 million for upper North Island health boards.

The commission had found that services in Auckland were fragmented, under-funded and needed leadership.

Sound familiar? In 1996, Judge Ken Mason delivered a landmark report stating that services were in disarray because of a lack of money and leadership. It led to the commission's creation. That report followed his damning criticism in 1988 of the then Auckland Hospital Board's psychiatric services.

The commission's latest Auckland recommendations included the appointment of a general manager of regional mental health services - "yet another bureaucracy" in the view of the Australian and New Zealand College of Psychiatrists.

The commission also called for a coalition of stakeholders, "adequate" funding, and expansions of key services.

Many in the sector consider under-funding to be the root problem, and it's easy to see why.

The commission wrote a blueprint on the quantity of services needed to implement the Government's mental health strategy. That amount would be enough to care for the 120,000 people nationally - the 3 per cent of the population thought to be suffering from a severe bout of depression, schizophrenia or other mental illness in any six-month period. They are among the 20 per cent of the population who experience a mental illness at some point in their lives.

Last year, only 1.4 per cent of people in the Auckland-Northland region used public mental health services - 47 per cent of the blueprint target and well below the national average of 57 per cent, itself a massive shortfall.

State funding for mental health services has more than doubled in the last decade, to $760 million a year, but this may obscure decreases associated with the closure of Carrington and other big psychiatric institutions.

Part of the Government's response to last year's review was to bring forward $12.8 million in funding from future years for the Auckland and Midland regions.

Some of the money is designed to allow patients to be moved out of the Auckland acute units - those who can be cared for in facilities owned by non-government organisations, although with a fairly high level of support, freeing up acute unit beds for others.

The extra money was welcomed by many groups, but the psychiatrists' college remains unconvinced.

The earliest the Government has said the blueprint could be fulfilled is 2010 because of the difficulties of expanding the mental health workforce from its present 8500 staff to the needed 12,000.

Meanwhile, Alan Gundesen phones back.

More bad news: he says that while his boss was being interviewed for these articles, a patient on respite at the same rest-home as before attacked a nurse. The patient was admitted to Tiaho Mai's locked intensive-care unit.