Despite the myriad technological advances innovating the delivery and provision of healthcare – particularly into remote and regional areas – there remain significant impediments for non-metropolitan patients in accessing many high-quality services.
One area of health in which service delivery faces unique and serious challenges in regional and rural Australia is mental health.
The problems that patients face in non-metropolitan areas that require specialised mental health services are not insignificant. There is strong evidence that they simply do not have the same access as their peers in cities.
A recent Monash University study, the largest study into mental health services in Australia of its kind, found significant inequality in access to services between higher and lower socio-economic areas, including remote and regional Australia. It also found that services in disadvantaged areas were more likely to be provided by GPs than specialist psychiatrists or clinical psychologists.
While general practitioners are an essential part of the solution, they should not represent the totality of service provision. Rather, they should complement and enhance the core delivery of specialised mental health care by professional experts in the field.
But the practical reality for those suffering mental ill health in regional and country Australia is far from a cohesive model of service delivery and far removed from that enjoyed in metropolitan centres.
Put simply, access to mental health services is not enjoyed on an equitable basis. Regional and rural patients have no choice but to submit to a regime of ad hoc attendance of trained psychologists and psychiatrists if and when they are rostered to attend a local town or centre.
Outside these part time rosters, it is the permanent health professional (usually a GP, nurse or registrar) who must provide primary mental health services within their own field of experience and also within the context of their already high pressured workload as a rural health care provider.
It is into this environment, of a GP, nurse or registrar already managing the broadest possible range of issues, that the regional mental health patient presents himself or herself when facing an acute mental health episode with specific and complex needs.
The customary part-time provision of mental health services in regional areas is found seriously wanting.
At a time of crisis, health practitioners who may not have the skills or experience are having significant treatment decisions forced on them in a way that would not occur in more resourced centres, as evidenced by the following case studies.
Case Study 1
A young man with a history of depression and attempted suicide contacted a mental health helpline for assistance and was told to see his GP for treatment. He then presented at the Emergency Department of his local hospital, as he was fearful of attempting suicide again and was not taking his prescribed medication.
A psychiatric nurse examined him and then consulted a psychiatrist over the phone. The psychiatrist did not speak to the patient or read his notes and did not examine him.
The patient was discharged and told to see his GP and psychologist. Subsequently the patient called the mental health helpline two more times as well as his father; again he was told to see his psychologist.
He returned to hospital a second time and was seen by a psychiatric nurse who discharged him without any discussion or consultation with a psychiatrist.
The patient was taken by ambulance to hospital for a third time after an overdose. The patient hung himself in the Emergency Department waiting to see a psychiatric nurse.
In the three weeks before his suicide, he was never seen by a psychiatrist.
Case Study 2
A female patient was admitted to the psychiatric unit of a major regional hospital.
During admission she was examined by a “fly-in, fly-out” psychiatrist who attended the hospital once a week. In this patient’s case, Mental Health Care Plans and Risk Assessments were performed by psychiatric nurses and a resident medical officer, while important decisions concerning changes in medications and leave allowance were made by others because there was no attendance by a psychiatrist for six days a week.
Whilst an in-patient, the woman was allowed to walk outside the psychiatric unit, and during that time attempted suicide again, suffering significant brain and orthopaedic injuries after jumping from the hospital building.
She had only been examined on three occasions by a psychiatrist during the three weeks before the event.
Case Study 3
Another female patient admitted to the same psychiatric unit as Case Study 2. Again the patient was examined by an intern, a psychiatric registrar, and by a psychiatrist only once a week. At all other times healthcare decisions were made by nurses.
An “on call” psychiatrist was contacted to ask if the patient was allowed leave from the unit, specifically to walk outside the locked ward. The “on call” psychiatrist had never met the patient and did not read or have access to the patient’s records.
A decision was taken to allow the patient to go for a walk and she too jumped from the hospital building and died.
Inequality in access
Inequality in access is at the core of the mental health crisis facing rural Australia and characterised in these tragic outcomes.
This inequality is also present in the way that mental health emergencies are utilised. There is a well-established model of care for the provision of acute care services in an emergency and this is simply not applied to mental health patients in rural areas.
“Mental health emergencies can be as life-threatening as a cardiac arrest.”
Had these patients in these case studies been presented to their local country hospital with a medical crisis such as a cardiac arrest, car accident or other misadventure, it is possible that their outcome may have been different. The health professionals triaging and considering the immediate medical needs of the patient would have organised the transfer of that patient to a centre that could deal with the medical problems presented.
Mental health emergencies can be as life-threatening as a cardiac arrest. However we need to question whether a mental health patient would ever be evacuated to a major metropolitan centre if the local rural hospital they were admitted to could not provide the high-level care needed to save their lives.
If we are to accept that not every town can have a psychiatrist (though by no means should rural and regional centres have to accept this as a given) then surely we need to recognise and provide the same priority of a mental health crisis to any other health emergency and get those patients to the care they desperately need.
Rebecca Tidswell has extensive experience in litigation focusing on complex medical law issues. She has worked with clients of all ages and backgrounds who have suffered mental health issues and other issues including brain injuries, spinal injuries and general medical problems. She is a lawyer in Carroll & O’Dea’s Sydney practice.
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