Where Economic Necessity and Social Justice Converge
The deinstitutionalisation of mental health services in the late 20th and early 21st centuries promised those who had previously been disempowered, denied liberty and at times treated as sub-human a better life – greater liberty, social justice and respect. However, this promise has not always been met for a significant number of people. For many, deinstitutionalisation has instead resulted in a repetitive cycling through periods of crisis:
This cycle has also contributed to people with severe and persistent mental illness being significantly over represented in homelessness statistics and prison populations. In addition it has meant that many sufferers have been unable to take advantage of the opportunities widely available to others in our society in terms of health, employment, housing, education and social integration.
A further outcome is that crisis support, principally through acute, hospital-based services remains in constant and high demand. As the most expensive area of service provision it becomes increasingly difficult to fund and support. At this point economic necessity and social justice converge in the quest for a more effective system.
The Tasmanian Government’s recent report, Rethink Mental Health: A long term plan 2015-2025, recognises these issues. It highlights the creation of ‘Step-up, Step-down’ spaces to triage patients away from acute services as both more effective for the individual and more cost effective for the system. These services “provide a ‘step-up’ for consumers in the community needing an increased level of support with the aim of preventing an inpatient admission, or a ‘step-down’ or transitional arrangement for people whose illness has stabilised enough to be discharged from inpatient care but who still require support to develop living skills and community connections or to find housing” (Rethink Mental Health, 2015). The report also acknowledges the importance of long-term supported accommodation, saying that there is significant evidence that supported accommodation represents an effective alternative to hospital care.
The Royal Australian and New Zealand College of Psychiatrists, in their response to the Rethink Mental Health Report (Jan, 2016) reiterate this. In fact, they identified an increasing need for both community-based and accommodation services, particularly over the next 10 years, to cater both for the complex and emergent needs of those deinstitutionalised from state care, and also to cater for the increasing number of people with mental ill health resulting from drug and alcohol use. It called on the State Government to ensure there is both enough in-patient and community-based care to cater for those who can ultimately return to the community, and also that there are enough long-term, community-based care and accommodation options for those who can’t.
Accommodation services, however, have more to offer than just diverting people away from acute care, or for supporting those with long-term care needs. They can also provide a space where the individual has the opportunity to take back control of their own life. Working together with staff, they provide a space where a person can determine how and where they want to go with their lives, and be supported collaboratively in turning their aspirations and goals into reality. In this sense properly funded and resourced accommodation provision has the potential not just to stop a person cycling through a system, but to reset their lives so that they are, in fact, no longer part of the system at all, or live only on the periphery of the system.
With limited financial resources, and potentially increasing demand, the State Government is now faced with the difficult choice of how to redesign and fund all levels of service required in this system – including acute, hospital-based care, step-up/step-down services, supported, community-based accommodation and services for those living independently in the community. It is important that community-based care, including accommodation services, is recognised as providing the most cost effective chance for the individual to recover their health and sense of wellbeing.
(Acting) Chief Executive