The Annual Report of the Chief Psychiatrist of South Australia

2013-14

For more information Mental Health Strategy Policy and Legislation System Performance, Department for Health and Ageing PO Box 287 Rundle Mall Adelaide SA 5000 Telephone: 08 8226 1091 Facsimile: 08 8226 6235 ocp@health.sa.gov.au © Department for Health and Ageing, Government of South Australia All rights reserved. ISBN 978-1-74243-724-8. ABN 97 643 356 590.

Hon Jack Snelling MP Minister for Mental Health and Substance Abuse Dear Minister In accordance with s92 of the Mental Health Act 2009, I am pleased to submit the Annual Report of the Chief Psychiatrist for presentation to Parliament. This report provides an account of the functions of the Mental Health Act 2009 and Mental Health Strategy, Policy and Legislation for the financial year ending 30 June 2014, in compliance with the Department of Premier and Cabinet Circular on Annual Reporting requirements. Yours sincerely Dr Panayiotis Tyllis Chief Psychiatrist Director Mental Health Policy 30 September 2014

Foreword I came to dual roles of Chief Psychiatrist and Director of Mental Health Policy in 2011 with the objective to bring extensive operational knowledge and experience in SA mental health services to bear on the legislative, policy and strategic functions of the Mental Health Unit. I had the ambition to consolidate the functions of the position as described in Sections 89 to 92 of the Mental Health Act 2009, re-establish links with leaders in operational services, streamline the departmental Mental Health Unit with a clear agenda on strategy and reform that could relate with operational services across the SA on a level playing field, develop policy for the integration of mental health care across the different steps in the system and age range with a focus on accessible customer focused services, link a revitalised clinical network to the strategy and policy work of the Unit to ensure clinicians are able to inform and influence change to improve services, and establish strategic links with key representative bodies such as the SA branch of the Royal Australian and New Zealand College of Psychiatrists. Over 2013-14 what was the Mental Health and Substance Abuse Division was restructured, after the devolution of Substance Abuse, to be Mental Health Strategy, Policy and Legislation (MHSPL), with clear and important functions for the Department and ongoing mental health service planning and reform. 2013–14 has been a busy but rewarding year. Some of the key work and achievements are:

> Opportunities for collaboration around quality improvement and coordination of information management were strengthened and integrated relevant SA Health and LHN structures:

• The Strategic Mental Health Quality Improvement Committee continues to refine its role in bringing together Local Health Networks around peer service benchmarking and a shared learning environment around quality improvement drivers.

• The Mental Health Information Committee has re-established a forum for clinicians and information managers from health and mental health to come together with a focus on strategic information management issues across the various systems used in Mental Health Services. In early 2014, Information Management staff from the former division of Mental and Substance Abuse combined with Central Adelaide LHN based Information Management and Performance Monitoring Unit. The combined staff has played a crucial role in the development and implementation of jurisdictional participation in the IHPA national mental health costing classification study.

> A key recommendation of the Mental Health Review 2013 was the redistribution of resources across LHN’s and across hospital and community services. MHSPL worked with staff from SA Health finance, health intelligence and policy and commissioning, in partnership with an external consultant and the LHN’s, to develop a population based resource allocation model for mental health services which is currently awaiting finalisation. Potentially this will serve as a powerful tool for guiding future investment to match population need.

> Strategic reform activities were focused on two key areas. Firstly, the implementation of Council of Australian Governments (COAG) initiatives including Forensic Step Down Unit, intensive Home Based Support Services, Acute 24 Service and Crisis Respite Services. Secondly, the recontracting of non-government organisation (NGO) services in mental health as the majority of agreements were expiring on 30 June 2014. The work of MHSPL staff involved in coordinating and progressing this work is to be commended.

> Child and Adolescent Mental Health Service (CAMHS) finalised a new model of care in February 2014, however further work has been held in abeyance pending the external review into CAMHS, announced in June 2014. In recognition of the need for specific

focus on child and youth services, MHSPL has obtained approval for a part-time Deputy Chief Psychiatrist position dedicated to the area of child and youth to be established as a temporary position across a two year period.

> Work on establishing Youth Mental Health Services has continued and is at an advanced stage with implementation imminent. As with any significant system reform, there is still much work to do to ensure the successful implementation and continued development of Youth Mental Health Services across LHN’s.

> Policy work has included streamlining forensic mental health admissions to appropriate services, finalisation of electroconvulsive therapy guidelines and further work on sexual safety and a restraint and seclusion guidelines. Importantly, the Pathways to Care Policy Directive, Policy Guideline and Quick Reference Guide were released and a roadshow undertaken across all health networks to establish broad awareness of the policies. It is expected that LHN’s will develop and review local procedures and work instructions in line with Pathways to Care over the coming year.

> While the work involved in administering the Mental Health Act has continued, the review of the Act was labour intensive in order to achieve the level of consultation required. The final report that was submitted to Parliament represented a succinct appraisal of contemporary issues for mental health legislation in South Australia, along with a series of recommendations for revision of the Act.

I wish to thank each member of the staff of MHSPL for their commitment, dedication and for working long hours, often through quite trying times, to the delivery of high quality, flexible and efficient services to people with mental illness. Specifically Ben Sunstrom, Mark Leggett and Kaaren Dahl warrant special mention for their unwavering commitment, fearless and honest approach and leadership support throughout my time in the department. Finally I wish to thank the people who matter most and without whose input effective mental health reform would be impossible. People who have personally experienced services and take the time to express their opinion, to provide feedback on services, review documents and participate at different levels of the care and governance spectrum. Dr Panayiotis Tyllis Chief Psychiatrist

1

Contents 1. Introduction 3 2. Patient and Service Reporting 4 2.1 Patient Demographics 4 2.2 Mental Health Treatment Orders 9 2.3 Restraint and Seclusion 14 2.4 Electro-Convulsive Therapy 15 2.5 Services and Service Use 17 2.6 Treatment and Care Plans 19 3. Mental Health Act 2009 20 3.1 Advice and Liaison 20 3.2 Amendments and Regulations 20 3.3 Authorisations and Delegations 20 3.4 Cross-Border Arrangements 20 3.5 Education and Training 21 3.6 Emergency Services Memorandum of Understanding 22 3.7 Forms and Statements of Rights 21 3.8 Inspections 22 3.9 Mental Health Treatment Orders 22 3.10 Officers authorised under the Act 22 3.11 Review of the Act 23 4. Statewide Strategic Service Improvement 24 4.1 Aboriginal and Torres Strait Islander People 24 4.2 Consumer and Carer Participation 25 4.3 Council of Australian Government Projects 26 4.4 Culturally and Linguistically Diverse People 28 4.5 Electro-Convulsive Therapy 28 4.6 E-Mental Health and EPAS 28

4.7 Forensic Mental Health Services 29 4.8 Non-Government Organisation Services 29 4.9 Other Legislation 30 4.10 Pathways to Care 31 4.11 Restraint and Seclusion 31 4.12 Safety, Quality and Risk 32 4.13 Sexual Safety 32 4.14 South Australian Mental Health Training Centre 32 4.15 South Australian Suicide Prevention Strategy 33 4.16 Strategic Planning 34 4.17 Youth Mental Health Services 36

5. Other Functions 37 6. Looking Forward 38 Appendix I – Glossary 39 Appendix II – Bibliography 41 Appendix III – Publications and Resources 42 Appendix IV – Forms and Statements of Rights 43 Appendix V – Mental Health and Related Services in South Australuia 44

2

Acknowledgements MHSPL would like to thank the numerous contributors to this report, both for the contribution to content but also for the work it represents in the preceding year within South Australian mental health services: Australian Bureau of Statistics, Data and Reporting Services DHA, Emergency Triage and Liaison Service CHSALHN, Forensic Mental Health Services NALHN, Guardianship Board, Information Management and Performance Monitoring Unit CALHN, Information Systems Standards and Quality DHA, Mental Health Triage CALHN, Population-Based Resource Allocation Model Committee DHA, Ramsay Health Care, Safety Quality Risk CALHN, South Australian Mental Health Training Centre, South Australian Police.

Annual Reporting Requirements The 2013 Annual Reporting Requirements of the South Australian Department of the Premier and Cabinet outlines the requirements for the content of South Australian government annual reports, within the statutory obligations of any relevant Acts. Section 12(1) of the Public Sector Act 2009 requires that all public sector agencies make an annual report to that agency’s Minister. Section 12(3) provides that a public sector agency that is also under another statutory obligation to make an annual report may incorporate those reports. Accordingly, information regarding the finances, service agreements and workforce of the MHSPL and other SA mental health services are contained in the SA Health Annual Report 2013-14.

Data Caveat This report contains an analysis and presentation of data regarding South Australian mental health service delivery during the fourth year of operation of the Mental Health Act 2009. The data have been obtained from various sources, which are not always directly comparable. Care has been taken in the presentation, analysis and attribution of data so that the reader can more accurately interpret information from different datasets, services and periods.

Terminology Many abbreviations and acronyms are used in the report. Please see the glossary in Appendix I for names and descriptions in full.

3

1. INTRODUCTION The position of Chief Psychiatrist is a statutory position established by the Mental Health Act 2009 to promote the continuous improvement of mental health services, monitor the treatment of patients and the use of restrictive practices, monitor the administration of the Act and advise the Minister on issues relating to psychiatry. The Chief Psychiatrist is required by section 92 of the Act to present an annual report to the Minister before 30 September each year. The Annual Report provides information about who receives mental health services, the use of the Act and the strategic service improvement undertaken by MHSPLt and collaborators across the community, services and agencies.

1.1 National Context Mental health policy, planning and service delivery in South Australia has been shaped and aligned to the Fourth National Mental Health Plan, the National Mental Health Policy 2008, the National Standards for Mental Health Services 2010 and the COAG National Action Plan on Mental Health 2006-11.

1.2 State Context Mental health policy, planning and service delivery in South Australia has been shaped and aligned to the Social Inclusion Board’s Stepping Up Report, South Australia’s Strategic Plan 2011, the SA Health Strategic Plan 2008-10, the Mental Health Act 2009 and South Australia’s Mental Health and Wellbeing Policy 2010-15.

1.3 Governance In 2013-14 the Chief Psychiatrist was the Executive of Mental Health Strategy, Policy and Legislation, a part of the System Performance Division of the Department for Health and Ageing. The Chief Psychiatrist had a dual reporting arrangement: to the Minister for Mental Health and Substance Abuse as a statutory officer and to the Deputy Chief Executive System Performance as an Executive.

1.4 Role and function of the Chief Psychiatrist The Chief Psychiatrist of South Australia also functions as the Director of Mental Health Policy and the Executive of Mental Health Strategy, Policy and Legislation. In 2013-14 MHSPL carried out statewide strategy, planning, policy and legislative functions from both a legislative and departmental perspective. MHSPL had no operational responsibility for mental health services, that being the function of the LHNs. MHSPL carries out a number of statewide strategic functions, described in detail in this Report, including: Information and Performance Management, Inter-Government and –Agency Collaboration, Mental Health Reform, NGO Service Development, Policy and Legislation, Safety Quality Risk, Statutory Functions, Strategic Planning and Strategic Service Improvement

4

2. PATIENT AND SERVICE REPORTING

2.1 Patient Demographics 2.1.1 Gender Tables 2.1.1 and 2.1.2 display the gender of people across the population, community mental health settings and inpatient mental health settings. Table 2.1.1 – Gender in community settings Program SA pop ICC CRC Forensic

cmty Supp *

accom CMHS IPRSS* All

CTOs Female 50.7 55.1 38.1 15.4 44.7 49.5 42.1 35.3 Male 49.3 44.9 61.9 84.6 55.3 50.5 54.9 64.7 Source: CARS, CBIS, HIP, ABS 3235.0 Population by A ge and Sex (*2012-13 data)

Table 2.1.2 – Gender in inpatient settings Program CAMHS

acute Adult acute

Older acute

PICU Forensic inpatient

Adult extended

Older extended

All ITOs

Female 63.8 49.8 55.7 36.0 17.3 21.1 18.0 45.0 Male 36.2 50.2 44.3 64.0 82.7 78.9 82.0 55.0 Source: CARS, CBIS, HIP

The South Australian population is distribured almost evenly between women (50.7%) and men (49.3%). Settings with similar gender division include CMHS and adult acute inpatient services. Settings with bias towards women are ICCs, CAMHS acute and older acute services. Setting with bias towards men are CRCs, forensics, supported accommodation, IPRSS, PICU, adult extended and older extended care. Of those people subject to orders, 64.7% of people on CTOs were male and 55.0% of people on ITOs were male. 2.1.2 Aboriginality Tables 2.1.3 and 2.1.4 show the number of Aboriginal and Torres Strait Islander people across the population, community service settings and inpatient service settings. Table 2.1.3 – Aboriginality in community settings Program SA pop ICC CRC Forensic

cmty Supp *

accom CMHS IPRSS* All

CTOs Number 31 949 55 9 34 6 2493 77 145 Percent 1.9 4.4 6.2 8.9 3.9 6.7 7.0 9.6 Source: CARS, CBIS, HIP, ABS 1379.0.55.001 Regional Profile SA (*2012-13 data)

Table 2.1.4 – Aboriginality in inpatient settings Program CAMHS

acute Adult acute

Older acute

PICU Forensic inpatient

Adult extended

Older extended

All ITOs

Number 39 364 2 49 13 10 - 332 Percent 9.9 6.1 0.3 12.9 25.0 52.6 - 5.0 Source: CARS, CBIS, HIP

Aboriginal and Torres Strait Islander people make up 1.9% of the South Australian population. They make up a greater proportion of patients in mental health settings, averaging around 6% in CRCs, community services, IPRSS and adult acute inpatient services. Aboriginal people are under-represented in older acute and older extended settings, and are over-represented in forensics, CTOs, CAMHS acute, PICU and adult extended settings.

5

2.1.3 Age The population of South Australia has a reasonably even distribution across adult age categories, with a moderate peak for people under 15 and decreasing numbers of people per category over 65, as per Figure 2.1.1. Tables 2.1.5, 2.1.6 and 2.1.7 show the age of the state population and of people across a number of community and inpatient settings. From those tables and Figures 2.1.1, 2.1.2 and 2.1.3, it can be seen that most (75%) people are 0-64 years old, most IPRSS was provided to 25-54 year olds, most ICC residents were 25-54 years old, most community services were provided to 0-54 year olds and most CTOs were used on 25-54 year olds. Table 2.1.5 – Age in SA population, IPRSS and suppo rted accommodation Age Group SA pop IPRSS* Supp accom *

No % No % No % 0-15 290 659 17.7 - - - - 16-24 220 860 13.5 25 2.3 12 7.9 25-34 214 651 13.1 260 23.6 59 39.1 35-44 220 971 13.5 308 27.9 35 23.2 45-54 228 899 14.0 263 23.9 32 21.2 55-64 201 981 12.3 134 12.2 11 7.3 65-74 136 253 8.3 48 4.3 2 1.3 75-84 87 269 5.3 62 5.6 - - 85+ 38 071 2.3 2 0.2 - - Total 1 639 614 100 1102 100 152 100 Source: CARS, CBIS, ABS 3235.0 Population by Age an d Sex (*2012-13 data)

Table 2.1.6 – Age in community settings and on CTOs

Age Group

ICC CRC FMHS cmty CMHS All CTOs

No % No % No % No % No % 0-15 - - - - - - 7506 20.2 2 0.1 16-24 162 12.8 32 21.8 43 11.2 6005 16.2 130 8.6 25-34 291 23.0 55 37.4 107 27.9 6156 16.6 378 24.9 35-44 330 26.0 37 25.2 117 30.5 6169 16.6 438 28.9 45-54 291 23.0 15 10.2 70 18.3 4859 13.1 294 19.4 55-64 163 12.9 7 4.8 29 7.6 2797 7.5 160 10.5 65-74 26 2.1 1 0.7 17 4.4 1734 4.7 71 4.7 75-84 4 0.3 - - - - 1304 3.5 35 2.3 85+ - - - - - - 569 1.5 9 0.6 Total 1267 100 147 100 383 100 37098 100 1517 100 Source: CBIS, HIP

For inpatient settings, contrasting against most of the population being 0-64 years old, most adult acute services were provided to 25-64 year olds, most PICU services to 25-54 year olds, most forensic services to 25-44 year olds and most ITOs placed on 15-54 year olds.

Figure 2.1.1 – State population by age group

6

Table 2.1.7 – Age in inpatient settings and on ITOs Age

Group CAMHS acute Adult acute Older acute PICU Forensic

inpatient All ITOs

No % No % No % No % No % No % 0-14 68 17.3 91 1.5 - - - - - - 49 0.7 15-24 324 82.7 710 11.8 - - 66 17.3 7 13.5 902 13.6 25-34 - - 1315 21.9 - - 112 29.4 19 36.5 1388 21.0 35-44 - - 1333 22.2 - - 103 27.0 15 28.8 1377 20.8 45-54 - - 1240 20.7 2 0.3 70 18.4 6 11.5 1174 17.8 55-64 - - 768 12.8 17 2.6 27 7.1 5 9.6 708 10.7 65-74 - - 314 5.2 306 47.4 3 0.8 - - 501 7.6 75-84 - - 204 3.4 254 39.4 - - - - 371 5.6 85+ - - 21 0.4 66 10.2 - - - - 143 2.2 Total 392 100 5996 100 645 100 381 100 52 100 6613 100 Source: CBIS, HIP

Figure 2.1.2 – CMHS by age group Figure 2.1. 3 – Acute inpt svcs by age group 2.1.4 Cultural and Linguistic Diversity Tables 2.1.8 and 2.1.9 display CALD status across the population and service settings. Table 2.1.8 – CALD status in community settings Program SA pop ICC CRC Forensic

cmty Supp *

accom CMHS IPRSS* All

CTOs Number 143 917 97 9 49 13 2386 58 171 Percent 8.8 7.7 6.1 12.8 8.6 6.4 5.3 11.3 Source: CARS, CBIS, HIP, ABS 31120DO0006 Migration (*2012-13 data)

Table 2.1.9 – CALD status in inpatient settings Program CAMHS

acute Adult acute

Older acute

PICU Forensic inpatient

Adult extended

Older extended

All ITOs

Number 20 552 116 29 2 1 11 654 Percent 5.1 9.2 18.0 7.6 3.8 5.3 22.0 9.9 Source: CARS, CBIS, HIP

7

2.1.5 Residence Tables 2.1.10 and 2.1.11 and Figures 2.1.4 through 2.1.8 display the residence of people receiving various services against the mental health service catchments. The catchment boundaries and populations are those from the Population-Based Resource Allocation Model work undertaken in collaboration by MHSPL and the LHNs, based on uptodate ABS population numbers. The catchments are listed in order of population size, from largest to smallest, to assist comparing service use against population in each catchment. Country catchments are shaded blue in the tables for clarity. Compared to population, the country catchments of Inner Rural, North West and Riverland South East show on par with population CMHS use, slightly lower CTO use and lower inpatient and ITO rates. Compared to population, the metropolitan catchments show: West with higher inpatient and ITO rates; East with lower CMHS and higher inpatient rates; North East with on par rates; Inner South with lower CMHS rates; North with higher CMHS rates; and the Outer South with on par rates. Table 2.1.10 – Residential region for the SA popula tion, community services and CTOs SA pop CMHS All CTOs Region No % No % No % Inner Rural 271 722 16.6 6613 17.8 164 10.8 West 224 044 13.7 4634 12.5 238 15.7 East 217 463 13.3 3314 8.9 239 15.8 North East 193 214 11.8 3520 9.5 176 11.6 Inner South 186 833 11.4 2651 7.1 160 10.5 North 176 829 10.8 5011 13.5 186 12.3 Outer South 163 392 10.0 3874 10.4 124 8.2 North West 109 992 6.7 3598 9.7 60 4.0 South East 96 125 5.9 2718 7.3 71 4.7 Unknown - - 657 1.8 47 3.1 Interstate - - 508 1.4 52 3.4 Total 1 639 614 100 37098 100 1517 100 Source: CARS, CBIS, HIP, ABS 3218.0 Regional Popula tion Growth, ABS 3222.0 Population Projections

Figure 2.1.4 – Residence by MH catchment

8

Table 2.1.11 – Residential region for inpatient ser vices and ITOs CAMHS acute Adult acute Older acute All ITOs Region No % No % No % No % Inner Rural 60 15.5 712 12.2 72 11.4 717 10.8 West 59 15.2 1084 18.6 90 14.2 1160 17.5 East 44 11.3 1053 18.0 86 13.6 885 13.4 North East 32 8.2 742 12.7 121 19.1 875 13.2 Inner South 39 10.1 682 11.7 79 12.5 834 12.6 North 53 13.7 597 10.2 78 12.3 792 12.0 Outer South 60 15.5 593 10.2 79 12.5 711 10.8 North West 28 7.2 219 3.7 18 2.8 165 2.5 South East 13 3.4 160 2.7 11 1.7 168 2.5 Unknown - - - - - - 225 3.4 Interstate - - - - - - 81 1.2 Total 392 100 5888 100 645 100 6613 100 Source: CARS, CBIS, HIP

Figure 2.1.5 – CMHS patients by region Figure 2.1.6 – CTOs by region

Figure 2.1.7 – Acute inpatients by region Figure 2.1.8 – ITOs by region

9

2.2 Mental Health Treatment Orders During 2013-14 there were 8130 mental health treatment orders active. Table 2.2.1 summarises these orders and contrasts them to the previous three years. The use of orders has remained consistent across the first 4 years of the operation of the Act. Table 2.2.1 – Mental health treatment orders Order type

Orders 2010 -11 Orders 2011 -12 Orders 2012 -13 Orders 2013 -14 No % No % No % No %

CTO1 192 2.4 172 2.0 186 2.3 200 2.5 CTO2 1685 20.9 1404 16.6 1358 16.7 1317 16.2 All CTOs 1877 23.3 1576 18.7 1544 19.0 1517 18.7 ITO1 4493 55.7 5059 60.0 4779 58.8 4847 59.6 ITO2 1552 19.2 1644 19.5 1673 20.6 1614 19.9 ITO3 149 1.8 155 1.8 135 1.7 152 1.9 All ITOs 6194 76.7 6858 81.3 6587 81.0 6613 81.3 Total 8071 100 8434 100 8131 100 8130 100 Source: CBIS

Table 2.2.2 and Figures 2.2.1 and 2.2.2 displays the ages of people subject to orders. Table 2.2.2 – Age of people on orders Age group

CTO1 CTO2 ITO1 ITO2 ITO3 No % No % No % No % No %

0-15 1 0.5 1 0.1 46 0.9 3 0.2 0 0.0 16-24 19 9.5 111 8.4 712 14.7 176 10.9 14 9.2 25-34 43 21.5 335 25.4 1077 22.2 293 18.2 18 11.8 35-44 64 32.0 374 28.4 1034 21.3 314 19.5 29 19.1 45-54 34 17.0 260 19.7 856 17.7 298 18.5 20 13.2 55-64 21 10.5 139 10.6 488 10.1 201 12.5 19 12.5 65-74 8 4.0 63 4.8 302 6.2 175 10.8 24 15.8 75-84 6 3.0 29 2.2 233 4.8 116 7.2 22 14.5 85+ 4 2.0 5 0.4 99 2.0 38 2.4 6 3.9 Total 200 100 1317 100 4847 100 1614 100 152 100 Source: CBIS

Figure 2.2.1 – All CTOs by age Figure 2.2.2 – All ITOs by age

10

2.2.1 Level 1 Community Treatment Orders Level 1 CTOs can last for up to 28 days and can be made by an authorised health professional or medical practitioner. A CTO1 not made by a psychiatrist or authorised medical practitioner must be reviewed by a psychiatrist within 24 hours or as soon as practicable. Multiple Orders The 200 CTO1s were made for 193 people, with 186 individuals (96.4%) having one CTO1 and seven individuals (3.6%) having two CTO1s. Order Outcomes Table 2.2.3 shows the outcomes of the CTO1s made. Table 2.2.3 – CTO1 outcomes

Outcome 2011-12 2012-13 2013-14

Number Percent Number Percent Number Percent Orders made 172 100 186 100 200 100 Expiry – maximum 146 84.9 151 81.2 176 88.0 Expiry – less than max 26 15.1 35 18.8 24 12.0 Revoked at 24-hour review 7 4.1 - - 8 4.0 Subsequently revoked 11 6.4 11 5.9 15 7.5 Went for intended duration 154 89.5 175 94.1 177 88.5 Source: CBIS

Duration 88.0% of CTO1s went for the maximum 28 days, with a minor peak of 8% lasting 5-7 days. 2.2.2 Level 2 Community Treatment Orders Level 2 CTOs can last for up to 365 days and can be made by the Guardianship Board on application by a health professional or other person with a proper interest in the welfare of the patient. Multiple Orders There were 1317 CTO2s made for 997 people, with 706 individuals (70.8%) having one CTO2, 263 (26.4%) having two, 27 (2.7%) having three and 1 (0.1%) having four. Order Outcomes Table 2.2.4 shows the outcomes of the CTO2s made. Table 2.2.4 – CTO2 outcomes

Outcome 2011-12 2012-13 2013-14

Number Percent Number Percent Number Percent Orders made 1404 100 1358 100 1317 100 Expiry – maximum 1302 92.7 1248 91.9 1221 92.7 Expiry – less than max 102 7.3 110 8.1 96 7.3 Revoked at 24-hour review - - - - - - Subsequently revoked - - 8 0.6 6 0.5 Went for intended duration 1399 99.6 1350 99.4 1311 99.5 Source: CBIS

Duration CTO2s had a range of durations, from 13 days to 365 days, with 1211 (92.7%) going for one year and a minor peak of 44 (3.3%) going for 6 months.

11

2.2.3 Level 1 Inpatient Treatment Orders Level 1 ITOs can last for up to 7 days and can be made by an authorised health professional or medical practitioner. All ITO1s must be reviewed within 24 hours, or as soon as practicable, by a psychiatrist or authorised medical practitioner, who cannot be the same clinician who made the order. Making the Order Of the 4847 ITO1s made in 2013-14, 4056 (83.7%) were made by Medical Practitioners and General Practitioners, 382 (7.9%) were made by Authorised Health Professionals, 207 (4.3%) were made by Psychiatrists, 134 (2.8%) by Authorised Medical Practitioners and 68 (1.4%) were incorrectly coded in the database. Those ITO1s were made in a variety of settings: 58.8% were made in metropolitan hospital Emergency Departments, 25.5% were made in metropolitan hospital wards, 10.0% were made in community settings (residential addresses, GP clinics and other locations), 4.9% were made in community mental health centres, 0.5% were made in country hospital Emergency Departments, and 0.2% were made in country hospital wards. Multiple Orders There were 4847 ITO1s made for 3715 people, with 2950 (79.4%) having one ITO1, 532 (14.3%) having two ITO1s, 155 (4.2%) having three ITO1s and 78 (2.1%) having four or more ITO1s. Order Outcomes Table 2.2.5 shows the outcomes of the ITO1s made. Table 2.2.5 – ITO1 outcomes

Outcome 2011-12 2012-13 2013-14

Number Percent Number Percent Number Percent Orders made 5059 100 4779 100 4847 100 Expiry – maximum 2105 41.6 2992 62.6 3225 66.5 Expiry – less than max 1326 26.2 1586 33.2 1291 33.5 Revoked at 24-hour review 1628 32.2 - - 1344 27.7 Subsequently revoked 562 11.1 - - 540 11.1 Went for intended duration 2867 56.7 2419 50.6 2962 61.1 Source: CBIS

Duration Table 2.2.6 shows the intended and actual duration of ITO1s. Table 2.2.6 – ITO1 durations Duration 0 1 2 3 4 5 6 7 8 Total

Intended No - 65 34 48 117 524 834 3225 - 4847 % - 1.3 0.7 1.0 2.4 10.8 17.2 66.5 - 100

Actual No 300 1102 129 133 140 383 557 2082 21 4847 % 6.2 22.7 2.7 2.7 2.9 7.9 11.5 43.0 0.4 100

Source: CBIS

12

2.2.4 Level 2 Inpatient Treatment Orders Level 2 ITOs can last for up to 42 days and can be made by a psychiatrist or authorised medical practitioner for a patient that is on an ITO1. Of the 1614 ITO2s made, xxx (x.x%) had a preceding ITO1 registered with MHSPL. Multiple Orders There were 1614 ITO2s made for 1345 people, with 1128 people (83.9%) having one ITO2, 179 (13.3%) having two ITO2s, and 38 (2.8%) having three to five ITO2s. Order Outcomes Table 2.2.7 shows the outcomes of the ITO2s made. Table 2.2.7 – ITO2 outcomes

Outcome 2011-12 2012-13 2013-14

Number Percent Number Percent Number Percent Orders made 1644 100 1673 100 1614 100 Expiry – maximum 1488 90.5 1427 85.3 1504 93.2 Expiry – less than max 156 9.5 238 14.2 110 6.8 Revoked at 24-hour review - - - - - - Subsequently revoked 1019 62.0 979 58.5 908 56.3 Went for intended duration 624 38.0 694 41.5 706 43.7 Source: CBIS

Duration ITO2s had a range of durations: 10 (0.6%) went for 1-7 days, 21 (1.3%) went for 8-14 days, 16 (1.0%) went for 15-21 days, 16 (1.0%) went for 22-28 days, 31 (1.9%) went for 29-35 days, 123 (7.6%) went for 36-41 days and 1397 (86.6%) went for 42 days. 2.2.5 Level 3 Inpatient Treatment Orders Level 3 ITOs can last for up to 365 days and can be made by the Guardianship Board on application by a health professional or other person with a proper interest in the welfare of the patient. Multiple Orders There were 152 ITO3s made for 130 people, with 112 (86.2%) having one ITO3, 15 (11.5%) having two ITO3s, two (1.5%) having three ITO3s and one (0.8%) having four ITO3s. Order Outcomes Table 2.2.8 shows the outcomes of the ITO3s made. Table 2.2.8 – ITO2 outcomes

Outcome 2011-12 2012-13 2013-14

Number Percent Number Percent Number Percent Orders made 155 100 135 100 152 100 Expiry – maximum 117 75.5 28 20.7 35 23.0 Expiry – less than max 38 24.5 69 51.1 117 77.0 Revoked at 24-hour review - - - - - - Subsequently revoked 33 21.3 37 27.4 54 35.5 Went for intended duration 122 78.7 98 72.6 98 64.5 Source: CBIS

Duration ITO3s had a range of durations from 29 days to 365 days, with peaks of 58 (38.2%) at 3 months, 32 (21.1%) at 6 months and 35 (23.0%) at 12 months.

13

2.2.6 Appeals The data systems of MHSPL and the GSB are not compatible and the information provided here is indicative only. Of the total 8130 mental health treatment orders made in 2013-14, 424 (5.2%) were appealed to the GSB and 51 (0.6%) were appealed to the District Court. Appeals to the Guardianship Board An appeal against a mental health treatment order may be made to the GSB by: the person to whom the order applies; the Public Advocate; a guardian, medical agent, relative, carer or friend; or any other person who satisfies the GSB that they have a proper interest in the matter. In practice appeals regarding CTO1s and ITO2s are made to the GSB. Table 2.2.9 displays the outcomes for the 424 appeals made to the GSB for the total of 1814 CTO1s and ITO2s made in 2013-14. 2.2.9 – Appeals to the Guardianship Board and outco mes Outcome Withdrawn at /

before hearing Varied Upheld Revoked Revoked

before hearing Number 76 21 43 30 96 % appeals 18.0 4.9 10.2 7.0 22.5 % orders 4.2 1.2 2.4 1.6 5.3 Outcome Lapsed Discharged Dismissed

and varied Dismissed Total

Number 16 39 46 57 424 % appeals 3.9 9.2 10.9 13.4 100 % orders 0.9 2.1 2.6 3.1 23.4 Source: GSB

Appeals to the District Court An appeal against a decision or order of the GSB may be made to the DC by: the applicant to proceedings before the GSB; the person to whom proceedings relate; the Public Advocate; any person who gave evidence or made submissions to the proceedings; or any other person who satisfies the GSB or DC that they have a proper interest in the matter. In practice appeals regarding CTO2s and ITO3s are made to the DC. Table 2.2.10 displays the outcomes of the 51 appeals made to the DC for the total of 1469 CTO2s and ITO3s made in 2013-14 2.2.10 – Appeals to the District Court and outcomes Outcome Appeal

allowed Appeal

dismissed Appeal

remitted Appeal stayed

Appeal struck

Appeal withdrawn

Total

Number 1 22 5 3 1 19 51 % appeals 2.0 43.1 9.8 5.9 2.0 37.3 100 % orders 0.07 1.5 0.3 0.2 0.07 1.3 3.5 Source: GSB

14

2.3 Restraint and Seclusion The mental health services of South Australia remain committed to reducing, and where possible eliminating, the use of restraint and seclusion. In addition to information in the medical records of consumers, the recording of restraint and seclusion data for mental health services was transferred in 2013-14 from a stand-alone database to the SA Health Safety Learning System. In 2013-14 there were 1649 restraint and seclusion events recorded for 711 people, with 1461 events for 572 people in mental health inpatient settings and 188 events for 139 people in emergency department settings. The 572 people who experienced restraint or seclusion in mental health inpatient settings represent 7.7% of the total 7427 admissions to public mental health wards. Across South Australia the rate of restraint per 1000 bed days was 4.6, the rate of seclusion per 1000 bed days was 4.2 and the combined rate per 1000 bed days was 8.8. Tables 2.3.1, 2.3.2 and 2.3.3 show the event type, event duration and event cause respectively. 47.3% of events recorded were mechanical restraint, followed by 33.5% of events being seclusion. 67.5% of events lasted under 4 hours, followed by 20.7% of events lasting between 4 and 8 hours. Most events had multiple causes, as reflected in Table 2.3.3. Table 2.3.1 – Restraint and seclusion events by typ e Type of Event Number Percent Restraint – mechanical 780 47.3 Restraint – physical 203 12.3 Restraint – chemical 96 5.8 Seclusion 558 33.8 Unknown 12 0.7 Total 1649 100 Source: SLS Table 2.3.2 – Restraint and seclusion event duratio n Duration CAMHS Adult Older Total No % No % No % No % < 4 hours 72 98.6 672 76.2 369 53.2 1113 67.5 4-8 hours 1 1.6 149 16.8 191 27.5 341 20.7 8-12 hours - - 45 5.1 115 16.6 160 9.7 > 12 hours - - 17 1.9 18 2.6 35 2.1 Total 73 100 882 100 694 100 1649 100 Source: SLS Table 2.3.3 – Reason for event

CAMHS Adult Older Intrusive behaviour 40 Aggression 477 Unintentional harm to self 399 Aggression 35 Intrusive behaviour 391 Aggression 153 To treat (MHAct) 21 To treat (MHAct) 220 Intrusive behaviour 123 To prevent leaving 12 To prevent leaving 158 Wandering 58 Deliberate harm to self 8 Deliberate harm to self 119 To treat (MHAct) 29 Property damage 8 Property damage 68 Deliberate harm to self 26 Unintentional harm to self 8 Wandering 56 Property damage 21 Wandering 8 Unintentional harm to self 39 To prevent leaving 11 S56 (MHAct) 6 S56 (MHAct) 28 S56 (MHAct) 1 Emergency (Consent Act) 5 Emergency (Consent Act) 5 To transport 1 To transport 1 To transport 3 Emergency (Consent Act) - Source: SLS

15

2.4 Electro-Convulsive Therapy Prescribed treatment is defined by the Act as Electroconvulsive Therapy (ECT), neurosurgery for mental illness or any other treatment declared by regulation to be prescribed treatment. ECT is the only prescribed treatment practiced in South Australia ECT is a specialised medical procedure where controlled seizures are induced under general anaesthesia. ECT is performed by a qualified multidisciplinary team that includes a psychiatrist and an anaesthetist. ECT is only used in specific circumstances, most commonly to treat major depression and sometimes other serious mental illness such as acute mania, catatonia and schizophrenia. In South Australia ECT is administered in 6 public hospitals: Flinders Medical Centre, Glenside Hospital, Lyell McEwin Health Service, Modbury Hospital, the Queen Elizabeth Hospital and the Repatriation General Hospital, and 2 private hospitals: the Adelaide Clinic and Fullarton Private Hospital. 2.4.1 ECT Service Use Table 2.4.1 compares the patients and treatments across public and private settings from 2011-12 to 2013-14. There was a moderate decrease in the number of public patients and public treatments in 2013-14. Table 2.4.1 – ECT use

Service setting

2011-12 2012-13 2013-14 People Treatments People Treatments People Treatments No % No % No % No % No % No %

Public 341 46.5 3659 66.9 399 72.4 4259 68.5 306 63.8 3701 57.9 Private 212 38.3 2400 33.1 198 33.2 2212 34.2 174 36.3 2696 42.1 Total 553 100 5469 100 551 100 6220 100 480 100 5778 100 Source: HIP, Ramsay Health

2.4.2 Gender In public settings, 196 (64.1%) of people receiving ECT were female and 110 (35.9%) were male. In private settings, 109 (62.6%) were female and 65 (37.4%) were male. 2.4.3 Aboriginality and CALD Status In public settings, there were 21 people of Aboriginal or Torres Strait Islander origin who received ECT, making up 6.9% of the total 306 people. This proportion is similar to the broad percentage of Aboriginal presentation to inpatient and community mental health services. In public settings there were 54 people (17.7%) from non-English speaking countries who received ECT. This is higher than the 8.8% in the general population and the proportions who receive inpatient and community mental health services. In private settings there were 11 people (6.3%) with CALD backgrounds.

16

2.4.4 Age Table 2.4.2 shows the age of people in public and private settings receiving ECT. Public setting ECT use climbs moderately for 25-34 year olds, peaks for 45-54 year olds and plateaus for 55-84 year olds. Private setting ECT use climbs moderately for 20-49 year olds, peaks for 50-69 year olds and decreases for 65-89 year olds. Table 2.4.2 – Age for ECT in public and private set tings

Public Private Age Group No % Age Group No % 0-15 - - 0-19 2 1.1 16-24 1 0.5 20-29 16 9.2 25-34 28 9.3 30-39 25 14.4 35-44 39 12.9 40-49 30 17.2 45-54 77 25.1 50-59 37 21.3 55-64 52 17.0 60-69 37 21.3 65-74 50 16.5 70-79 20 11.5 75-84 56 18.2 80-89 6 3.4 85+ 2 0.6 90-99 1 0.6 Total 306 100 Total 174 100 Source: HIP, Ramsay Health

2.4.5 Diagnoses Table 2.4.3 displays the diagnoses for people receiving ECT in public and private settings. Table 2.4.3 – Diagnosis for ECT in public and priva te settings

Diagnosis Public Private

No % No % Depressive disorders 209 68.2 167 95.8 Schizo-affective disorders 50 16.4 - - Bi-polar disorders 44 14.2 7 4.2 Other disorders 3 1.1 - - Total 306 100 174 100 Source: HIP, Ramsay Health

2.4.6 Treatments per patient Figure 2.4.1 shows the number of ECT treatments per public patient for 2013-14. Of the total 306 people, 61 (19.9%) received 1-6 treatments, 154 (50.3%) received 7-12 treatments, 39 (12.7%) received 13-18 treatments, 33 (10.8%) received 19-24 treatments and 19 people (6.2%) received 25 or more treatments. The higher treatment numbers represent people who were acutely unwell and had more than one course of ECT in the year, or those people who receive regular treatments to maintain their health and wellbeing.

Figure 2.4.6 – Treatments per person

17

2.5 Services and Service Use 2.5.1 Mental Health Facilities and Services Table 2.5.1 – Treatment centres, beds and separatio ns Treatment Centre Wards Beds * Seps

No % No % Adelaide Clinic 56 10.8 852 10.3 Flinders Medical Centre 4G, 5H, 5J, 5K 43 8.3 959 11.6 Glenside Campus Eastern Acute, Eastern PICU,

Grove Closed, Helen Mayo House, Rehabilitation Ward, Rural and Remote, 101 19.5 1130 13.6

James Nash House Aldgate, Birdwood, Clare 30 5.8 45 0.5 Lyell McEwin Health Service 1G, 1H 46 8.9 796 9.6 Modbury Hospital Woodleigh 20 3.9 466 5.6 Noarlunga Health Service Morier 20 3.9 430 5.2 Oakden Services for Older People Clements, Makk, McLeay 64 12.4 50 0.6 Royal Adelaide Hospital C3 25 4.8 1252 15.1 Repatriation General Hospital Ward 17, Ward 18 54 10.4 734 8.9 The Queen Elizabeth Hospital Cramond, Ward South East 41 7.9 976 11.8 Whyalla Hospital Integrated MH Unit 6 1.2 20 0.2 Women’s and Children’s Hospital Boylan 12 2.3 569 6.9 Total 518 100 8279 100 Source: HIP, Ramsay Health. (* beds numbers on 30 J une 2014, excluding flex beds) Table 2.5.2 – Public inpatient service types, beds and separations Service Type Wards Beds * Seps

No % No % CAMHS acute Boylan 12 2.6 392 5.3 Adult acute 1G, 4G, 5H, 5K, C3, Cramond, Eastern Acute,

Helen Mayo House, Morier, Rural and Remote, Ward 17, Woodleigh, Whyalla Ward 203 43.9 5888 79.3

Older acute 1H, Ward 18, Ward South East 70 15.2 645 8.7 PICU 1G PICU, 5J, Cramond PICU, Eastern PICU,

Morier HDU 33 7.1 381 5.1 Forensic inpatient Aldgate, Birdwood, Clare, Grove Closed 40 8.7 52 0.7 Adult extended Rehabilitation Ward 40 8.7 19 0.3 Older extended Clements, Makk, McLeay 64 13.9 50 0.7 Total 462 100 7427 100 Source: HIP, Ramsay Health. (* beds numbers on 30 J une 2014, excluding flex beds) Table 2.5.3 – Public community service settings, be ds/places and consumers Service Setting Location No Intermediate Care Metro and country 65

Total residents / consumers 1267 Community Rehabilitation Metro: Elpida, Trevor Parry, Wondakka 60

Total residents 147 Supported Accommodation Housing and Accommodation Support Program 79

Other supported accommodation programs 34 Supported Social Housing Metro and country houses 258 Community Mental Health Total contacts 663 265

Total consumers 37 098 Average contacts per person 17.9

IPRSS (2012-13 data) Total hours across metro and country 197 489 Total consumers 1102 Average hours per person 179

Source: CARS, CBIS, HIP

18

Tables 2.5.1 to 2.5.3 from the previous page display services and service use across inpatient and community settings. Adult secure rehabilitation, JNH and Oakden had a markedly lower proportion of separations to beds, indicating extended care settings. 2.5.2 Emergency Services Table 2.5.4 shows the total and mental health use of emergency responses across the state. Table 2.5.4 – Emergency service use Service Occasions of Service No %

Mental Health Triage (metropolitan calls)

Total incoming calls 2013-14 62 402 100 Outbound, returned calls, referrals 47 524 76.2 MHT answer query 9216 14.8 Abandoned 5662 9.1

Emergency Triage and Liaison Service (country calls)

Total incoming calls 2013-14 25 000 100 ETLS answer query ≈ 12500 50.0 For referral / case management ≈ 12500 50.0

SA Ambulance Service Total SAAS events 2010-11 307 000 100 Mental health events 2010-11 3187 1.03

SA Police Total police taskings 2013-14 400 642 100 Mental health taskings 2013-14 4161 1.04

RFDS Total transfers 2012-13 6259 100 Mental health transfers 2012-13 297 4.7

Metropolitan Emergency Department Total presentations 2013-14 382 826 100 Mental health presentations 13 026 3.4 Drug and alcohol presentations 4244 1.1

Source: ETLS, HIP, MHT, RFDS, SAAS, SAPol

2.5.3 Length of Stay Table 2.5.5 shows the average length of stay across emergency departments in hours and bedded services in days. Table 2.5.5 – Average length of stay Category Presentation type 2011-12 2012-13 2013-14

Metropolitan emergency department General presentation 4.4 4.4 4.6 Drug and alcohol presentation 6.1 6.5 7.1 Mental health presentation 8.8 10.5 12.4

Category Service type ALOS Days

Public hospital inpatient services All admissions 3.6 Primary diagnosis mental health 8.9 All mental health wards combined 18.4

Mental health inpatient stream

CAMHS acute 4.8 Adult acute 14.2 Older acute 38.0 PICU (Cedars, 5J) 12.6 Forensic inpatient 158.6 Adult extended 243.1 Older extended 184.2

Residential stream ICC 9.7 CRC 209.00

Source: HIP

19

2.6 Treatment and Care Plans Sections 39, 40 and 41 of the Act outline the requirements for treatment and care plans respectively for voluntary inpatients, patients to whom level 2 community treatment orders apply and patients to whom level 2 or level 3 inpatient treatment orders apply. These sections require that, as far as practicable, the treatment and care of an individual should be governed by a plan and that the plan should be prepared and revised in consultation with the patient and, if appropriate, other people who are providing support. Table 2.6.1 displays if the care plan screens in CBIS – the electronic Community Based Information System used to record community and some inpatient mental health patient data for adults across metropolitan Adelaide – have been updated or revised during or shortly after a person’s mental health treatment order. Information regarding children and adolescents, inpatients and country people is held in other electronic records systems and is not reflected in the Table. Additionally, treatment and care plans that are only placed in a person’s medical records or community case notes are not reflected in the Table. Table 2.6.1 – CBIS care plans updated during or aft er an order Order Type

Required by Act

Required by GSB

2011-12 2012-13 2013-14 No % No % No %

CTO1 - - 46 26.6 51 27.4 36 18.0 CTO2 Yes Yes 744 53.0 715 52.7 576 43.7 ITO1 - - 784 15.5 4779 21.9 759 15.7 ITO2 Yes - 497 30.2 1673 32.3 400 24.8 ITO3 Yes Yes 73 47.1 135 41.5 53 34.9 Source: CBIS

Although the data presented here is incomplete and is only indicative, it is widely accepted that treatment and care plan use and quality requires improvement. To this end, MHSPL and the LHNs will work together in 2014-15 on the matter in a Working Group of the Strategic Mental Health Quality Improvement Committee.

20

3. MENTAL HEALTH ACT 2009

3.1 Advice and Liaison

MHSPL provided advice and liaison to clinicians and services, other government agencies, NGOs, statutory offices, and consumers and families on: ˃ Mental Health Act 2009 regarding: appeals, authorised officer powers, authorised health

professional powers, authorised medical practitioner powers, ECT consent and use, forms, information sharing, mental health treatment orders, restraint and seclusion use and notification, statements of rights, treatment centres, and treatment and care plans.

˃ Mental Health Emergency Services Memorandum of Understanding: processes, collaboration and forms.

˃ Cross-border arrangements available for individuals moving between jurisdictions. ˃ Section 269 of the Criminal Law Consolidation Act 1935 regarding processes and options

for forensic mental health patients.

3.2 Amendments and Regulations

There were no amendments to the Act or the Regulations in 2013-14.

3.2 Authorisations and Delegations

MHSPL worked with the CSO in March 2014 to draft instruments of authorisation and delegation for various Act functions. The instrument of authorisation for ITO3s was completed in April 2014 and the instrument of delegation from the Minister to the Parliamentary Secretary in July 2014. Further instruments will be completed in late 2014.

3.3 Cross-Border Arrangements

3.3.1 Chief Psychiatrist Standard MHSPL released the Cross-Border Arrangements Chief Psychiatrist Standard and Plain Language Guide for the transfer of care of patients between South Australia and other States and Territories in January 2014. The Standard sets out the mandatory process for South Australian and other jurisdictions to consider, carry out and report cross-border arrangements. 3.3.2 Consumer Arrangements Part 10 of the Act makes a number of provisions for the treatment and transport of individuals between South Australia and other Australian jurisdictions. During 2013-14 there were: ˃ One instance of a person on a South Australian Level 1 ITO escorted interstate to

continue their care and treatment ˃ One instance of a person on a South Australian Level 2 ITO absconding interstate

where they continued to be monitored by family and Mental Health services. ˃ One person on an interstate CTO relocating to South Australia and requiring inpatient

care. ˃ One person on an interstate ITO in South Australia requiring transfer back to their

interstate Mental Health Service.

21

˃ Two instances of a person on a South Australian Level 2 CTO relocating interstate without notice. Mental Health Service interstate briefed.

˃ Two instances of the use of s69, where the Chief Psychiatrist made a level 1 CTO for a person in South Australia, where a CTO existed interstate, so that they may continue their care and treatment.

3.3.3 Memoranda of Agreement During 2013-14 South Australia maintained existing Memoranda of Agreement with New South Wales and Victoria for the treatment, care and transport of people on mental health treatment orders between jurisdictions.

3.4 Education and Training

The use and administration of the Act requires mental health services, general health services, emergency services, government departments, NGOs, statutory offices, consumers and carers to understand the Act provisions and how they relate to rights and service provision. MHSPL provided education and training to 1090 people from across these diverse groups on: ˃ Authorised officer “care and control” powers. ˃ Information sharing. ˃ Mental Health Act 2009. ˃ Mental Health and Emergency Services MOU 2010. ˃ Safe and respectful patient search protocols.

3.5 Emergency Services Memorandum of Understanding

The Mental Health and Emergency Services Memorandum of Understanding 2010 is an agreement between the Royal Flying Doctor Service, South Australian Ambulance Service, SA Health and South Australian Police that outlines the cross-agency collaboration and communication to be used to facilitate the assessment and treatment of people who may have a mental illness. The MoU is governed by a Steering Committee at the statewide level and by Local Liaison Groups at the regional level. The Steering Committee is responsible for monitoring the operations of the MoU and considering issues that have statewide impacts, and the LLGs for improving processes and communication at the local level and reviewing complex cases that may provide further learnings. In 2013-14 the Steering Committee commenced a formal review and report on the functioning of the MoU, which will be completed when potential changes from the Review of the Mental Health Act 2009 have been considered.

3.6 Forms and Statements of Rights

No changes were made in 2013-14 to the 12 mandatory or 3 optional forms for the use of the Act. The four Statements of Rights, available in English and 15 other languages, also remained unchanged.

22

3.7 Inspections

The Act gives the Chief Psychiatrist the authority to conduct inspections of the premises and operations of any facility that is incorporated hospital under the Health Care Act 2008. This power was exercised to conduct an audit of treatment and care plans in the patient records of an inpatient team and a community team in August 2013. The recommendations from this audit have been submitted to the Strategic Mental Health Quality Improvement Committee for consideration and implementation, and have led to NALHN working to improve uptake and quality.

3.8 Mental Health Treatment Orders

MHSPL carried out the data entry, legal acknowledgements and quality control required for the 8130 mental health treatment orders made during 2013-14.

3.9 Officers authorised under the Act

3.9.1 Authorised Officers Authorised Officers are mental health clinicians, ambulance officers and RFDS medical officer and flight nurses who have powers under s56(3) of the Act to take a person into care and control, transport, restrain, administer medication (if also authorised to do so under the Controlled Substances Act 1984), enter a place, search a person’s clothes and possessions and assist other authorised officers. Police officers have similar powers under s57(4), with the addition of being able to break and enter a property. The Chief Psychiatrist can define additional classes of people as mental health clinicians and thus as authorised officers for the purposes of administering the Act only. Those classified as mental health clinicians and thus as authorised officers in 2013-14 were:

> Employees of public mental health services, comprising: Aboriginal health workers, occupational therapists, psychiatrists, psychologists, registered nurses and social workers.

> Employees of public emergency departments as authorised by the Director of an emergency department, comprising: medical practitioners and registered nurses.*

> Employees of public country hospitals as authorised by the Executive Director Mental Health of CHSALHN, comprising: medical practitioners and registered nurses.*

> Employees of the prison health service, comprising: medical practitioners and registered nurses.

> Experienced custodial officers as authorised by the General Manager of a prison.*

> MedSTAR retrieval team staff, comprising: medical practitioners, paramedic officers and flight nurses.

> Privately employed psychiatrists. *CHSALHN, DCS and Modbury Hospital have not yet operationalized their AO capacity while they develop appropriate policies and procedures. 3.9.2 Authorised Health Professionals Authorised Health Professionals are experienced mental health clinicians who are authorised by the Chief Psychiatrist to be able to make Level 1 CTOs and Level 1 ITOs – to be reviewed by a psychiatrist within 24 hours – to ensure that consumers get immediate access to the

23

treatment and care they need. MHSPL is responsible for receiving nominations, training, authorising and registering, and providing ongoing peer review activities for AHPs. During 2013-14, 42 mental health clinicians completed the required two-day training and were subsequently authorised by the Chief Psychiatrist to be AHPs. A total of 202 AHPs are currently registered across the state, representing 9% of the total mental health workforce of approximately 2500. MHSPL delivered 16 half-day support sessions for AHPs with a total attendance of 333, providing participants with up-to-date information regarding issues and solutions, shared learning and maintaining currency of authorisation. 3.9.3 Authorised Medical Practitioners Authorised Medical Practitioners are senior psychiatric registrars or International Psychiatric Specialist Medical Graduates who receive specific training from the South Australian Psychiatric Training Committee (SAPTC) and are subsequently authorised by the Chief Psychiatrist to have the powers of a psychiatrist for the purposes of the Act. Ten medical practitioners completed the SAPTC AMP training during 2013-14 and one was subsequently registered as an AMP upon request by the employing LHN.

3.10 Review

Section 111 of the Act requires the Minister to provide a report to Parliament on the operation of the Act within 4 years of the commencement of the Act. In addition, s90(1) requires the Chief Psychiatrist to monitor the administration of the Act and promote continuous improvement of mental health services. The Office of the Chief Psychiatrist established the Mental Health Act User Group in August, 2010, to monitor, evaluate and provide advice regarding the operation of the Act. The User Group comprises stakeholders who are effected by or use the Act. From 2010 the Mental Health Act User Group has maintained an Issues Register of matters concerning the operation of the Act. The Register, and any actions taken to address the matters raised, are monitored by the User Group. Any issues legislative in nature have been deferred to the Review. The Review formally commenced in September, 2013, with a two month period of public submission. In addition, targeted consultation sessions were held with a broad range of stakeholders over three months.

> 23 targeted consultations were held, with consumers, carers, community mental health services, emergency services, inpatient mental health services, legal practitioners, Parliamentarians, private mental health services, statutory officers, unions and professional bodies.

> A total of 45 written submissions were received. The register, submissions and consultations identified a total of 301 matters for consideration. Of those, 160 (53%) were related to the Act, 127 (42%) were related to mental health service delivery and resourcing, and 14 (5%) were related to other legislation. Based on the collated feedback regarding the Act, MHSPL began the drafting of this Report in January 2014, considering developments in international human rights and changes to the mental health legislation in other Australian jurisdictions. A workshop was convened in April 2014, inviting individuals and agencies who had participated in the review to further debate and expand on key issues of particular complexity and importance. The additional detail gained informed the final drafting of: The Review of the Mental Health Act 2009 – A Report by the Chief Psychiatrist of South Australia, which was tabled in Parliament on 1 July 2014.

24

4. STATEWIDE STRATEGIC SERVICE DEVELOPMENT MHSPL has undertaken a number of strategic service development, planning and policy responsibilities in 2013-14, as detailed below.

4.1 Aboriginal and Torres Strait Islander People

National, State and SA Health strategy and policy requires the mental health and wellbeing needs of Aboriginal and Torres Strait Islander People to be an integral component of service planning and delivery. 4.1.1 Strategic Aboriginal Participation The MHSPL Aboriginal consultant participates in strategic service design, planning, implementation and review, including in 2013-14: Ongoing Statewide Strategic Participation Aboriginal Mental Health Reference Group, APY Lands Service Group, Central Adelaide Local Health Network Aboriginal and Torres Strait Islander Mental Health Committee, Mental Health and Substance Abuse Research Group, Rising Spirits Advisory Group, Southern Adelaide Local Health Network Aboriginal Mental Health Working Group, Statewide Mental Health Clinical Network, Statewide Mental Health Strategic Committee, Suicide Prevention Strategy for Aboriginal People Working Group, Youth Mental Health Implementation Committee. 4.1.2 Aboriginal Mental Health Action Plan During 2013-14, the Aboriginal Mental Health Reference Group provided oversight and advice regarding the implementation of the Plan. An Aboriginal Mental Health Working Group was established in each LHN and commenced implementation. Statewide priorities of the Action Plan progressing are: ˃ A survey of mental health services regarding Aboriginal cultural competency was carried

out. The findings and implications will be considered by the Statewide Mental Health Strategic Committee and the Aboriginal Mental Health Reference Group in 2014-15.

˃ Development of a Cultural Competency Learning and Development Program proposal for consideration by Aboriginal people, services and executive in 2014-15.

˃ Development of a South Australian Aboriginal Suicide Prevention Action Plan. ˃ Development of the Mental Health and Emotional Wellbeing Statement of

Acknowledgement, endorsed by the Statewide Mental Health Strategic Committee. The Statement will be sent for SA Health executive approval in late 2014.

4.1.3 Anangu Pitjantjatjara Yankunytjatjara Lands MHSPL continues to work with the Adelaide Football Club, the South Australian National Football League, Shine SA, and individuals and communities of the APY Lands, to deliver mental health promotion and education for people of the APY Lands, both on the Lands and in Adelaide. In July 2013, staff participated in the Rio Tinto Aboriginal Lands Challenge Cup Education Week in partnership with Shine SA to deliver education sessions to 60 APY youth on the topics of mental health and sexual health and wellbeing.

25

4.2 Consumer and Carer Participation

The National Mental Health Strategy, the National Standards for Mental Health Services 2010 and the Mental Health Act 2009 require the participation of people who have experienced mental illness, and of people who have cared for people who have experienced mental illness, in the planning and delivery of mental health services. 4.2.1 Strategic Participation The MHSPL consumer consultant and carer consultant participate in strategic service design, planning, implementation and review, including in 2013-14: Ongoing Statewide Strategic Participation Carer Advisory Group, Community Visitor Scheme Advisory Committee, Consumer Reference Group, GPSA Mental Health Shared Care Steering Committee, Individual Psychosocial Rehabilitation Support Service Program Management Committee, Mental Health Act 2009 User Group, Mental Health Review Implementation Committee, National Mental Health Commission Contributing Life Project Advisory Group, SA Health Partnering with Consumers and Community Advisory, Statewide Mental Health Implementation Committee, Statewide Mental Health Quality Improvement Committee, Statewide Mental Health Strategic Committee. Strategic Project Participation Child and Adolescent Mental Health Services Model of Care, Electro-Convulsive Therapy Protocols, Sexual Safety Guidelines, Intermediate Care Evaluation, Margaret Tobin Awards, Pathways to Care Policy series, National Mental Health Commission Contributing Life Project, Seclusion & Restraint Policy suite, Suicide Prevention Strategy, Veterans and Veterans’ Families Counselling Service Forum, Youth Model of Care Implementation.. 4.2.2 Statewide Mental Health Lived Experience Regi ster The Register is the mechanism by which MHSPL communicate with and facilitate the participation of consumers and carers regarding mental health planning and policy at a state level. At 30 June 2014 the Register had 150 registered members, with 102 (68%) identifying as people with personal experience of mental illness, 89 (59.3%) with lived experience of supporting someone with mental illness (89) and 46 (30.7%) as both. The Register won the 2013 SA Health Award for Consumer, Carer and Community Participation. 4.2.3 Lived Experience Workforce The Lived Experience Workforce is comprised of consumers and cares who are employed by public mental health services and NGOs – as consumer consultants, peer specialists, peer workers or carer consultants – to assist individuals and families engage with services, to advocate for the needs of individuals and/or their families, and to assist service providers to understand consumer and carer perspectives. During 2013-14, the Managers’ and Workers’ Working Groups of the Project combined as the Statewide Mental Health Lived Experience Workforce Development Project Reference Group. The group is currently developing a Lived Experience Workforce Policy and Standards for public mental health services, and also for the lived experience workforce in the non-government mental health sector.

26

4.3 Council of Australian Governments Projects South Australia is undertaking seven projects as part of COAG National Partnership Agreements. MHSPL has provided the planning, procurement and reporting requirements for the projects and has collaborated with the LHNs to implement them. In July 2010 Cabinet approved five projects to deliver 98 subacute bed equivalents under the Improving Public Hospital Services – National Partnership Agreement, including a Crisis Respite Service, Country Community Rehabilitation places, Forensic Step-Down Unit, National Perinatal Depression Initiative and Supported Accommodation. In June 2012 Cabinet approved the commencement of two projects under the Supporting National Mental Health Reform – National Partnership Agreement, including $9.46 million to expand the Assessment and Crisis Intervention Service (Acute 24) at three sites, and $4.7 million to establish a Community Walk-In mental health site in northern Adelaide. 4.3.1 Acute 24 The Acute 24 Project operates in each of the three metropolitan LHNs. The service ensures a 24 hour crisis intervention service in the Adelaide metropolitan area. The service commenced in March 2013 in NALHN, in June 2013 in the CALHN and in December 2013 in SALHN. The service provides crisis intervention services to people in their homes. The service also provides SAPOL and SAAS with an alternative to taking mental health consumers to emergency departments. The service is linked to Mental Health Triage. 4.3.2 Crisis Respite Service This project provides 24 facility based and 10 home based bed equivalents for early intervention services for people experiencing a mental health crisis. The 24 facility based beds are currently located at Level 7 of Highgate Park. The 10 home based bed equivalent service also operates from the same location. The project commenced operation on 30 June 2014 and provides a metropolitan wide service. Psychosocial support services are provided by NEAMI and SA Health staff provide clinical in-reach services. The program provides more local based options and more appropriate and timely out of hospital care for people experiencing a mental health crisis. 4.3.3 Community Walk-In Service The Community Walk-In Service located in Salisbury (originally located in John Street and from December 2012 at the new Northern Community Mental Health Centre in Park Terrace) opened on 13 August 2012. On 11 March 2013, the Walk-In Service commenced an expanded service from 9am-9pm, 7 days a week. The Walk-In Service has provided mental health consumers with an alternative to presenting to emergency departments. 4.3.4 Country Community Rehabilitation Service This project provides 20 additional subacute beds and rehabilitation services for people suffering a mental illness who reside in country South Australia. 10 of the beds are located in Whyalla and 10 beds are located in Mount Gambier. The project commenced operation on 30 June 2014. The services operates from leased houses and services are provided by SA Health staff. These subacute beds are the first in country South Australia. Adult country residents who require additional support to recover from a mental illness will be able to access services so they can lead independent lives in their communities.

27

4.3.5 Forensic Step-Down Unit This project provides 10 beds and intensive rehabilitation services to prepare forensic consumers for transition back into the community. The service commenced in September 2013 and operates out of a new purpose built facility known as Ashton House located next to James Nash House at Oakden. The step down facility provides patient with community rehabilitation services, care and skills that will prevent unnecessary readmissions to mental health facilities, reduce recidivism and reduce length of stay in secure forensic facilities. 4.3.6 National Perinatal Depression Initiative The NPDI was established by the Commonwealth Government to improve prevention and early detection of antenatal and postnatal depression and provide better support and treatment for expectant and new mothers experiencing depression. The NPDI enables the provision of: ˃ Routine and universal screening for depression for women during the perinatal period by

a range of health care professionals including midwives, child and maternal health nurses, mental health nurses, Aboriginal health workers, psychologists and general practitioners.

˃ Follow up treatment, support and care for women who are at risk of or, experiencing perinatal depression.

˃ Training and development for health professional to help them screen expectant and new mothers to identify those at risk of or experiencing perinatal depression.

˃ Community Awareness raising activities which aim to share knowledge and information to improve the understanding of the incidence, nature and treatment of depression in the perinatal period.

˃ Research and data collection including research into prevention activities. 4.3.7 Supported Accommodation This project provides supported accommodation services across metropolitan and country areas to support people with a mental illness in the community. The project commenced in June 2013 and provides 37 bed equivalents or 80 packages of care. Non-government sector agencies have been contracted to provide these services with SA Health staff providing clinical in-reach services. The project aims to reduce admissions to emergency departments, avoid long stays in acute units and meet subacute service and bed gaps for people with a mental health illness in South Australia by improving patient health outcomes, functional capacity and quality of life through more appropriate and timely out of hospital care.

28

4.4 Culturally and Linguistically Diverse People In 2013-14 MHSPL completed the drafting of the SA Health CALD Mental Health Strategy. The draft has been put on hold while SA Health and MHSPL restructure and reprioritise work in the current fiscally-restrained environment. MHSPL worked with SA Health, the LHNs and the National Mental Health in Multicultural Australia (MHiMA) consortium to support the introduction of the MHIMA Framework into South Australia and the pilot at 2 sites.

4.5 Electro-Convulsive Therapy To reflect the evolution of ECT practice, MHSPL worked in collaboration with the consumers and carers, the 6 public and 2 private ECT sites, anaesthetists, nurses and the Royal Australian and New Zealand College of Psychiatrists (SA Branch) over 18 months to draft a comprehensive and contemporary ECT Policy Guideline and ECT Chief Psychiatrist Standard to inform clinical practice. During 2013-14 the ECT Advisory Committee and Reference Group completed the drafting of the documents. The drafts were consulted in December 2013 with consumers, carers and public and private ECT treatment sites. The ECT Policy Guideline was endorsed on 11 February 2014 by the Safety and Quality Strategic Governance Committee and the ECT Chief Psychiatrist Standard was approved by the Minister for Mental Health and Substance Abuse on 1 July 2014. The ECT Policy Guideline will be submitted to Portfolio Executive in early 2014-15 for approval, prior to formal implementation in South Australia.

4.6 e-Mental Health and EPAS

A Memorandum of Agreement was signed in 2013-14 between the LHNs and MHSPL for the establishment of the Mental Health Information Committee, auspiced by the Information Management and Performance Monitoring Unit CALHN, to provide clinical information and reporting expertise at all levels from local operations to state and national reporting requirements. The Committee’s role is to draw together the clinical, information and administrative expertise of the multiple mental health and general health data systems, improve collaboration and coordination, facilitate consistent practice and improve data for clinical-decision making, service planning and state and national reporting. The Committee and the Unit manage and advise regarding the three stand-alone community mental health data systems – CBIS, CCCME and BART – and the mental health content of EPAS and relevant data on other SA Health legacy systems.

29

4.7 Forensic Mental Health Services

4.7.1 Strategic Partnerships MHSPL, NALHN and FMHS continue to be engaged with the other involved agencies to review and improve cross-agency communication and collaboration for people made subject to s269 orders of the Criminal Law Consolidation Act 1935, including the: Chief Justice, Chief Judge, Chief Magistrate, Commissioner for Victim’s Rights, Courts Administration Authority, Department of Correctional Services, Disability SA, Exceptional Needs Unit, Legal Services Commission, Office of the Director of Public Prosecutions, Parole Board, Police, Police Prosecutions, Public Advocate, SA Prison Health Service and Youth Justice. 4.7.2 Case Management MHSPL collaborated with NALHN, FMHS, and the Department of Correctional Services to monitor and plan for the custody, supervision and care of forensic patients with complex clinical and/or legal considerations. 4.7.3 Forensic Court Liaison Program MHSPL funded NALHN to provide the Forensic Court Liaison Program in 2013-14 as a pilot for consideration as an ongoing service. The pilot will be evaluated in late 2014. 4.7.4 Policy and Practice Improvement Forensic Mental Health Patient Admission to SA Heal th Facilities Policy Directive MHSPL worked with FMHS, NALHN, RAH emergency department and relevant Unions and professional bodies to finalise and publish the Policy Directive in January 2014. Mental Health Treatment for Prisoners MHSPL worked with the CSO to draft a Chief Psychiatrist memo outlining the legal considerations for people under DCS supervision receiving mental health treatment in prison, in the community and in SA Health facilities. The memo was released in June 2014. Use of Ministerial Directions MHSPL, NALHN and the OCE monitored and improved the protocols for the making of a Ministerial Direction for forensic patients requiring accommodation outside a dedicated FMHS facility.

4.8 Non-Government Organisation Services NGO services continue to be an integral part of the stepped system of mental health care in South Australia. They enable people who experience mental illness to stay well in the community and reduce the need for emergency, acute and other facility based services. NGOs are funded to provide a range of services to people with mental illness and their carers and families. These include: individual psychosocial rehabilitation and support services, housing and accommodation support services, group programs, services on referral from general practitioners, information and support services, support to expand the role of people with lived experience of mental illness, support to beyondblue and suicide prevention programs. Services offered by NGOs are diverse and assisted more than 10,000 South Australians in the past year. 4.8.1 Advice and Liaison MHSPL provided advice and liaison for consumers, carers and families, NGOs, mental health services and other agencies regarding the interpretation and application of service

30

guidelines for people seeking to access programs. MHSPL assisted consumers, NGOs and mental health services with mediation to resolve issues. 4.8.2 Community Support Services MHSPL provided the administrative, finance and coordination support for people with mental illness to receive HACC-funded packages of support, comprising: domestic assistance, personal care, social support, respite and home maintenance. 309 consumers accessed the scheme in 2013-14, for a total of 32 525 hours, averaging just over 2 hours a week per person. 4.8.3 Interagency Collaboration MHSPL have engaged with other government and NGO agencies to: roll out the Family Safety Framework, develop a coordinated domestic squalor and hoarding response, enhance government processes to assist and support people with exceptional needs, explore options for a trial of social impact bonds, plan for the for transition to the full scheme of the National Disability Insurance Scheme, provide activities for Mental Health Week, participate in the administrative and governance requirements of the Memorandum of Agreement with Housing SA. 4.8.4 Procurement and Contracting A number of agreements with NGO providers expired on 30 June 2014. A review of currently funded programs was undertaken within the department, together with consideration of the requirement to contribute to Government savings targets. Consideration was also given to those programs that may be in scope for inclusion in the full scheme implementation of the National Disability Insurance Scheme. An extensive procurement process was undertaken to offer new agreements for ongoing programs. NGO service providers have also been involved in offering services as part of two of the six sub-acute projects funded by the Australian Government via the Council of Australian Governments. 4.8.5 Strategic Planning MHSPL has undertaken a number of strategic planning activities concerning NGOs in 2013-14, including: work to update the psychosocial service standards for the NGO sector, the development of models of care for service initiatives funded through the Council of Australian Governments (COAG), discussions about local implementation of the Partners in Recovery program, and developing services of two of the six sub-acute projects funded by the Australian Government via the Council of Australian Governments.

4.9 Other Legislation MHSPL worked in collaboration with other parts of the Department for Health and Ageing, the LHNs and other Government Departments to draft, review and/or implement other legislation relevant to the Mental Health Act 2009 and mental health services. 4.9.1 Advance Care Directives Act 2013 MHSPL worked closely with the SA Health leads to develop mental health content for the whole of enterprise information and training resources for communities and clinicians, to be used when the Act is operationalised from 1 July 2014.

31

4.9.2 South Australian Civil and Administrative Tri bunal Act 2013 MHSPL collaborated with the Attorney-General’s Department to work through issues and amendments to the SACAT Bill, Regulations and Business Rules, and the transfer of the functions of the Guardianship Board to the Community Stream of SACAT.

4.10 Pathways to Care

During 2012-2013 MHSPL engaged in extensive consultation with consumers, carers, mental health services, general health services, emergency departments, non-government organisations, peak bodies, statutory offices, professional bodies and unions to identify how the mental health system in South Australia can continue to evolve towards an integrated community-based customer-focussed recovery-oriented system. The Pathways to Care Policy Directive, Policy Guideline and Quick Guide were released in May 2014, to enhance the strengths, use the opportunities and address the gaps of the current system to meet the requirements of the Stepping Up and the National Mental Health Strategy reform agendas. The policies are written in plain language and are designed to improve a consumer’s experience of mental health services and the capacity of staff and services to address needs. The Policies encompass eight key areas of mental health service provision: participation, access, care and treatment, transfer of care, working with others, exiting, re-entry and transport. Implementation of the Policies will be undertaken by the LHNs in collaboration with service partners, with support by MHSPL. The Policies will be evaluated against existing key performance indicators, using existing systems and processes.

4.11 Restraint and Seclusion

The Mental Health Services of South Australia remain committed to the reduction, and where possible the elimination, of the use of restraint and seclusion. The National Standards for Mental Health Services 2010 and the Mental Health Act 2009 require that mental health services be provided in the least restrictive way in the least restrictive environment possible, consistent with providing effective treatment and care. The monitoring and review of restraint and seclusion is carried out in collaboration by MHSPL and the LHNs through the Restraint and Seclusion Steering Committee and the Strategic Mental Health Quality Improvement Committee. The SAMHTC supports LHNs by providing accredited Non-Violent Crisis Intervention training and refresher courses. The Restraint and Seclusion for Mental Health Patients Policy Guideline, Chief Psychiatrist Standards, Toolkit and Education Package has been developed over the past two years by the MHSPL and was released for community and service consultation in late 2013. The restraint and seclusion policy suite will be released in late 2014.

32

4.12 Safety, Quality and Risk

During 2013-14 MHSPL continued its role in mental health safety, quality and risk matters with state-wide or strategic importance including: ˃ Chairing the Strategic Mental Health Quality Improvement Committee ˃ Membership of the SA Health Safety and Quality Strategic Governance Committee ˃ Monitoring and review of legislated and high risk mental health safety and quality

indicators ˃ Review of Coronial Inquest recommendations with statewide or system-wide mental

health implications Mental Health Services have a rigorous system of reporting adverse events and during 2013-14 decreased the reporting threshold of deaths of people who have had contact with mental health services to include: any event in relation to a person who has died within 6 months of discharge from a mental health service and any person who has had a significant clinical contact with a mental health service in the past 3 months but was not admitted to a service. Mental Health Services conducted a review of 137 deaths in the community from suicide and unknown causes in 2012 which made a total of 15 recommendations. These recommendations were reviewed and updated during 2013-14 to assess how the recommendations were being implemented and include; development of the SA Health Suicide Prevention Strategy, improved data reporting, clinical guidelines for the management of suicide and risk assessment training resources for all staff. MHSPL facilitated the completion of a gap analysis against the National Standards for Mental Health Services 2010 by LHNs during 2013-14. The results of this gap analysis facilitated the sharing of best practice initiatives across LHNs and identified opportunities for state-wide collaboration.

4.13 Sexual Safety MHSPL commenced drafting the Sexual Safety in Mental Health Services Policy Guideline in 2013-14, after broad and focussed consultation in 2012-13. The Guideline focuses on contemporary best-practice to keep people safe from experiencing or initiating unwanted sexual activity, particularly for women in inpatient settings, but is also applicable to other vulnerable groups and other settings. The Guideline will be released for community and service consultation in late 2014.

4.14 South Australian Mental Health Training Centre SAMHTC is funded by MHSPL and located on the Glenside Campus, to provide statewide strategic mental health education and training to mental health services, general health services, partner agencies, NGOs and community groups. In 2013-14 the education programs offered by SAMHTC were: Engaging Clients who display Challenging Behaviours, Identifying New Ways of Thinking, Mental Health Assessment and Risk Assessment Tool, Mental Health Care Plan, Mental Health First Aid, Mental Health Risk Assessment, Mental State Examination, Motivational Interviewing, Non Violent Crisis Intervention (full and refresher courses), and Team Building. 1023 people attended 125 learning events during that period.

33

SAMHTC facilitates the licensing of SA mental health clinicians for access to MHPOD, the national Mental Health Professional Online Development program. In 2013-14 970 SA staff were registered and using MHPOD. In addition, SAMHTC worked with SA Police to provide mental health training and site visits as part of the SA Police cadet training program.

4.15 South Australian Suicide Prevention Strategy

MHSPL continued to collaborate with all levels of Government and the community to implement the Strategy in 2013-14. 4.15.1 Suicide Prevention Networks Suicide Prevention Networks continue to be developed and supported around the state and located within local government regions. The networks comprise people from business, industry, community members, community groups, service clubs, education, emergency services, health service providers, other government and non-government organisations, and local government. MHSPL continues to facilitate and support local Suicide Prevention Networks, including: Network Auspiced by Status Action Plan Aboriginal Community of Pangula Mannamura and Burrandies

To be decided Forming To be developed

Back2Basics Clare and Gilbert Valleys Council

Established Completed

City of Murray Bridge Suicide Prevention Network

Country South SA Medicare Local

Established Completed

City of Playford Suicide Prevention Network

Northern Adelaide Medicare Local

Established Completed

CORES Riverland CORES Tasmania Established Not required Gawler Suicide Prevention Community Group

Town of Gawler Established Completed

Mid Murray Suicide Prevention Network

Mid Murray Council Forming To be developed

Mount Gambier Suicide Prevention Network

Lifeline South East Established Completed

Naracoorte, Lucindale and Districts Community Suicide Prevention Network

Naracoorte and Lucindale Council

Forming To be developed

Port Adelaide Suicide Prevention Network

Facilitated by Wesley Lifeforce Established Not required

SILPAG Port Augusta Facilitated by Wesley Lifeforce Established Not required Strathalbyn Suicide Prevention Network

Facilitated by Wesley Lifeforce Established Not required

Victor Harbor Suicide Prevention Network

Wellbeing and Mental Health, auspiced by Life Without Barriers

Forming To be developed

Whyalla Suicide Prevention Network Rural City of Whyalla Forming To be developed

MHSPL continues to collaborate with Wesley Lifeforce, an NGO with Federal grant funding for Network development, to include and connect SA Health and Wesley Lifeforce supported networks across the state.

34

4.15.2 SA Government Suicide Prevention Implementat ion Committee The Minister-appointed members of the South Australian Suicide Prevention Committee were instrumental in providing advice and support for the development of the Strategy and overseeing its initial implementation. The Committee was dissolved at the completion of member’s terms in March 2014 and planning commenced for the establishment of a SA Government Suicide Prevention Implementation Committee. 4.15.3 Future Suicide Prevention Activity The Government of South Australia has committed just over $1 million per annum for suicide prevention. In 2013-14 MHSPL began the planning for implementation of the commitments in 2014-15, comprising: ˃ $278,000 to Beyondblue for depression, anxiety and suicide awareness and prevention. ˃ $200,000 to Lifeline for their telephone crisis support service. ˃ $150,000 for local Suicide Prevention Networks to raise awareness, reduce stigma,

improve individual and community resilience and enhance referral pathways. ˃ $150,000 for small grants for local suicide prevention initiatives and activities. ˃ $125,000 to SA Health for a Suicide Prevention Officer to establish and support local

Suicide Prevention Networks and suicide prevention activities. ˃ $115,000 to Centacare for the Youth Suicide Intervention Service (known as Ascend).

4.16 Strategic Planning 4.16.1 Bed Planning In 2007 the Social Inclusion Board recommended that Government create a stepped system of care to suit the various stages of a person’s mental illness and deliver more places at the different levels of care closer to where they live in the community, including in the country for the first time. When the reforms were announced in 2007, South Australia had 513 inpatient and forensic beds, with an additional 64 extended care beds for elderly people with mental illness at Oakden Services for Older People. In 2013-14 MHSPL collaborated with the LHNs to implement additional beds and services for a total of 591 beds and places across the various mental health care types, comprising: ˃ 10 Bed Forensic Step-Down Unit at James Nash House, Oakden. ˃ 10 non-facility Crisis Respite Services to people in their own homes. ˃ 24 Crisis Respite Service facility based beds in the metropolitan area. 4.16.2 Housing Stock Management MHSPL oversees and manages the 79 Housing and Accommodation Support Program dwellings, the 34 other supported accommodation places and the 258 supported social housing dwellings to ensure each remains tenanted by a person with mental illness. MHSPL works in collaboration with the LHNs, Housing SA and Preferred Growth Providers (NGOs that provide housing support and management) to this end.

35

4.16.2 Population-Based Resource Allocation Model In 2013-14 MHSPL worked in collaboration with the LHNs and an external consultant to identify and analyse current mental health activity, boundaries, funding, population and staffing, and developed a Population-Based Resource Allocation Model for mental health services in South Australia. The PBRAM identifies statewide services and provides weightings for particular services, enabling the model to be altered as circumstances and systems change over time. The PBRAM identifies funding and staffing inequities against populations and provides recommendations for resource reallocation. Importantly, given current fiscal restraints, the PBRAM identifies resource allocation for future monies and planning so that population needs can be more evenly met going forward. 4.16.3 Management of Consumer Funds Consumers who experience extended stays in SA Health facilities, if they do not have Guardianship or Public Trustee arrangements in place, may have their finances managed by SA Health staff. Groups this may affect include: the elderly waiting for nursing home beds, forensic mental health patients receiving care for the duration of their limiting term, older people receiving aged extended mental health care and adults receiving extended rehabilitation mental health care. MHSPL drafted a Management of Consumer Funds Policy Directive in 2013-14 and sought Crown Solicitor Office advice to ensure its effectiveness. The Policy Directive outlines the rights and responsibilities of consumers and SA Health employees. In 2014-15 MHSPL will work with the broader Department and the LHNs to finalise and implement the Policy Directive. 4.16.4 Review of the Stepping Up Mental Health Reform The review was completed in July 2013 and primarily found that South Australia had sufficient mental health resources and capacity. The Deputy Chief Executive, MHSPL and the LHNs are responsible for the implementation of the 15 recommendations of the Review. In 2013-14 MHSPL completed 3 recommendations: ˃ Development of a Population-Based Resource Allocation Model to inform potential

resource movements and/or future resource allocation across LHNs and care types. ˃ Release of the Pathways to Care Policy Guideline and Policy Directive to better guide

how consumers obtain treatment. ˃ Streamlining and restructure of MHSPL and its strategy, policy and legislation functions. 4.16.5 Workforce Planning Workforce planning for 2013-14 had a focus on nursing, with the Mental Health Nurse Leaders’ Council undertaking: ˃ Commentary and feedback for the drafting of mental health and general health policy and

practice across the enterprise. ˃ Oversight of the use of the National Mental Health Core Capabilities July 2012. ˃ Review of the implementation of the SA Health Nursing and Midwifery Strategic

Framework 2013-15 for mental health nurses. ˃ Review of the nature of engagement with and observation of consumers in the mental

health nursing milieu.

36

4.17 Youth Mental Health Services

SA Health is committed to developing mental health service streams based on developmental appropriateness and individual need. There is significant evidence from around the world that the mental health requirements of children (0-15), youth (16-24), adults (25-64) and older people (65+) are different and that services should be streamed to cater for those differences. The establishment of youth mental health services in SA is consistent with international and national trends. There are limited youth specific services currently available for young people with emerging or existing mental illness. MHSPL chairs the CAMHS-Youth Mental Health Implementation Steering Committee and the CAMHS-Youth Mental Health Union Consultation Forum. During 2013-14 developments included: Operational Guidelines for Youth Mental Health Service, staff training plan and basic training modules; CAMHS staff transition plan for in-scope staff to LHN-based YMHSs; LHN service models and draft operational structures for YMHS for CALHN, CHSALHN and SALHN. Work has continued on the evaluation framework and consultation with staff and unions.

37

5. OTHER FUNCTIONS MHSPL out a variety of other functions as both a statutory office and a part of the Department for Health and Ageing.

5.1 Community Visitor Scheme MHSPL provided administrative, accounting, human resource and planning support to the CVS during 2013-14. MHSPL also progressed the expansion of the CVS into the disability and SRF sectors through leading the transfer of the administration of the Scheme from SA Health to DCSI.

5.2 Complaints and Inquiries MHSPL receives approximately 2500 telephone, email and mail inquiries and complaints each year from the public, service providers and other agencies regarding the Act, mental health services, non-government organisation services, mental health treatment orders and other matters.

5.3 GP PASA MHSPL provides the General Practitioner Psychiatrist Advice South Australia service to make appointments for patients referred by their GP to see a participating psychiatrist for assessment and a management plan under the Medicare Benefits Schedule. MHSPL coordinated 1138 appointments during 2013-14.

5.4 Parliamentary, Ministerial and Executive Functi ons MHSPL writes a range of Parliamentary, Ministerial and Executive documents. In 2013-14 these were: 371 Ministerial briefings and/or response letters, 37 Incoming Government Briefs, 24 Parliamentary Briefing Notes, 24 Parliamentary Questions and 20 Parliamentary Estimates requests. MHSPL also coordinated 217 Ministerial briefings and/or response letters for DASSA during this period.

38

6. LOOKING FORWARD Work has commenced to reinvigorate the implementation of the recommendations of the 2013 review of mental health services. In the current environment, the redistribution of resources to achieve a more equitable population based funding arrangement will be challenging. The work of Transforming Health will play a crucial role in this and the recent decision to include mental health services specifically in this process was welcomed. It is crucial that in the mental health space along with clinician groups that were established to inform Transforming Health, there is also consumer and carer groups consistent with the first recommendation of the National Mental Health Commission Report Card 2012 “nothing about us without us”. The implementation of LHN based YMHSs is imminent and represents the next step in the development of youth focussed services. Intensive staff training and consideration of other steps required in the system of care for youth will be important areas of work for 2014-15. In the legislation and policy context the passage through Parliament of the agreed amendments to the Act will require extensive consultation and time investment. MHSPL has enjoyed bipartisan support for some important areas of our work, such as suicide prevention. We look forward to working with Minister Snelling, Mrs Leesa Vlahos Parliamentary Secretary to the Premier and members of the Opposition and minor parties as we continue to advance mental health service delivery to South Australians. The structure and functions of Mental Health Commissions in interstate and international jurisdictions must be reviewed to inform the establishment of the South Australian Mental Health Commission. With the sustained focus on emergency department care and bed based solutions, along with the potential for activity based funding to incentivise hospital based care, it is important that an independent body is established to inform the strategic direction of future developments in mental health and ensure the continued strengthening of community based mental health services and the non-government sector. Clearly all the areas of change in the coming year cannot be easily captured here. The term “change fatigue” is often used to describe the experience of staff at all levels of the service. Change however is inevitable unless we are certain we have a perfect system. Even then the characteristics and circumstances of populations to which services provide care continue to change over time. Change therefore is part of our day to day work and we must maintain the energy required to design, implement and evaluate service improvements on an ongoing basis. I feel that after three years, it is time for renewed energy and enthusiasm to be brought to the role of Chief Psychiatrist and Director of Mental Health Policy in order to maintain the momentum for reform in mental health services in South Australia. For this reason I have chosen to return to a primarily clinical role in 2015, allowing a recruitment process for the Chief Psychiatrist and Director Mental Health Policy position to commence in late 2014. Dr Panayiotis Tyllis Chief Psychiatrist

39

Appendix I – Glossary A

ABS Australian Bureau of Statistics ACHS Australian Council on Healthcare Standards ACIS Assessment and Crisis Intervention Service AHP Authorised Health Professional ALOS Average Length of Stay AMP Authorised Medical Practitioner AO Authorised Officer APY Lands Anangu Pitjantjatjara Yankunytjatjara Lands ATSI Aboriginal and Torres Strait Islander ATC Approved Treatment Centre

B

BART Information system used to record and report CAMHS activity. C

CAG Carer Advisory Group CALD Culturally and Linguistically Diverse CAMHS Child and Adolescent Mental Health Services CARS Consumer Activity Reporting System CBIS Community Based Information System CCC Combined Country CME (Client Management Engine) CHSA Country Health South Australia CLCA Criminal Law Consolidation Act CMHC Community Mental Health Centre CMHS Community Mental Health Service COAG Council of Australian Governments CRC Community Rehabilitation Centre CRG Consumer Reference Group CTO Community Treatment Order CVS Community Visitor Scheme

D

DASSA Drug and Alcohol Services of South Australia DTO Detention and Treatment Order

E

ECT Electro-convulsive Therapy ED Emergency Department EPAS Enterprise Patient Administration System EPIS Early Psychosis Intervention Service ETLS Emergency Triage and Liaison Service

F FMC Flinders Medical Centre

G

GH Glenside Hospital GP General Practitioner GP PASA General Practitioner Psychiatrist Advice – South Australia GSB Guardianship Board of South Australia

H

HASP Housing and Accommodation Support Partnership HIP Health Information Portal

40

I

ICC Intermediate Care Centre ICT Information and Communication Technology IPRSS Individual Psychosocial Rehabilitation Support Service ISAAC Integrated South Australian Activity Collection ITO Inpatient Treatment Order

J

JNH James Nash House L

LHN Local Health Network LMHS Lyell McEwin Health Service LTC Limited Treatment Centre

M

MHA Mental Health Act 2009 MHESMoU Mental Health and Emergency Services Memorandum of Understanding 2010 MHiMA Mental Health in Multicultural Australia MHSPL Mental Health Strategy, Policy and Legislation MPH Modbury Public Hospital MP Medical Practitioner

N

NGO Non-Government Organisation NHS Noarlunga Health Service NPC Nurse Practitioner Candidate

O

OCPP Office of the Chief Psychiatrist and Mental Health Policy P

PAS Patient Administration System PECU Psychiatric Emergency Care Unit PICU Psychiatrist Intensive Care Unit

R

RAH Royal Adelaide Hospital RANZCP Royal Australian and New Zealand College of Psychiatry RFDS Royal Flying Doctor Service RGH Repatriation General Hospital

S

SAAS South Australian Ambulance Service SANFL South Australian National Football League SAPTC South Australian Psychiatric Training Committee SAPOL South Australian Police SLA Statistical Local Area

T

TQEH The Queen Elizabeth Hospital W

W&CH Women’s & Children’s Hospital Y

YMHS Youth Mental Health Services

41

Appendix II – Bibliography Clinician’s Guide and Code of Practice – Mental Health Act 2009. Department of Health, Government of South Australia (2010). Criminal Law Consolidation Act 1935 (South Australia). Fourth National Mental Health Plan – An agenda for collaborative government action in mental health 2009-2014. Fourth National Mental Health Plan Working Group, Government of Australia (2009). Guardianship and Administration Act 1993 (South Australia). Introduction to the Community Visitor Scheme – Mental Health Act 2009. Department of Health, Government of South Australia (2010). Mental Health Act 2009 (South Australia). Mental Health and Emergency Services Memorandum of Understanding 2010. Department of Health, Government of South Australia (2010). Mental Health Practitioner’s Guide to Sharing Consumer Information. Department of Health, Government of South Australia (2011). National Mental Health Policy 2008. Department of Health and Ageing, Commonwealth of Australia (2009). National Standards for Mental Health Services 2010. Commonwealth of Australia (2010). Plain Language Guide – Mental Health Act 2009. Department of Health, Government of South Australia (2010). South Australian Suicide Prevention Strategy 2012-16. Department for Health and Ageing, Government of South Australia (2012). South Australia’s Mental Health and Wellbeing Policy 2010-2015, Department of Health, Government of South Australia (2010) SA Health Strategic Plan 2008-2010, Department of Health, Government of South Australia (2008). South Australia’s Strategic Plan 2007, Government of South Australia (2007). Summary Report: Statewide Aboriginal Mental Health Consultation 2010. Department of Health, Government of South Australia (2010).

42

Appendix III – Publications and Resources Current mental health publications and resources available from SA Health. Publications > Clinician’s Guide and Code of Practice – Mental Health Act 2009

> Cross-Border Arrangements Chief Psychiatrist Standard and Plain Language Guide

> Forensic Mental Health Patient Admission to SA Health Facilities Policy Directive

> Mental Health Practitioner’s Guide to Sharing Consumer Information 2011

> Mental Health Services Pathways to Care Policy Guideline and Policy Directive

> Patient and Solicitor Access to Patient Records Chief Psychiatrist Standard

> Plain Language Guide – Mental Health Act 2009

> South Australia’s Mental Health and Wellbeing Policy 2010-15

> South Australian Suicide Prevention Strategy 2012-2016

> Summary Report: Statewide Aboriginal Mental Health Consultation 2010

> The Annual Report of the Chief Psychiatrist of South Australia 2010-11

> The Annual Report of the Chief Psychiatrist of South Australia 2011-12

> The Annual Report of the Chief Psychiatrist of South Australia 2012-13

> The Framework for Recovery-Oriented Rehabilitation in Mental Health Care 2012

> The Review of the Mental Health Act 2009 – A report by the Chief Psychiatrist of South Australia May 2014

Information and Training Resources > Act Amendments and Revised Forms – 1 hour presentation

> Authorised Health Professionals – 2 day training package for clinicians

> Authorised Officers – 1 hour presentation for emergency departments

> Information Sharing – 1 hour presentation for communities and clinicians

> Mental Health Act 2009 – 1 hour presentation for communities and clinicians

> Mental Health and Emergency Services MoU – 1 hour presentation for clinicians

> Safe Searching Procedures – 1 hour presentation for clinicians Mental Health Act Instruments and Agreements > Cross Border Agreement – New South Wales

> Cross Border Agreement – Victoria

> Mental Health and Emergency Services Memorandum of Understanding 2010

> Supported Social Housing MOAA 2013 – Housing SA and SA Health Fact sheets > Authorised Officers – Mental Health Act 2009

> Section 56 Powers Officers – Mental Health Act 2009

> Making and Confirming / Revoking Level 1 Orders – Mental Health Act 2009

> People and Powers – Mental Health Act 2009

> Safe Searching Procedures

43

Appendix IV – Forms and Statements of Rights Forms Mandatory

> MR82J Consent to Electroconvulsive Therapy

> MR82Q Patient and Solicitor Access to Patient Records

> MR82R Undertaking not to Divulge Requested Information

> MR90B Community Treatment Order level 1

> MR90C Inpatient Treatment Order level 1

> MR90D Confirmation/Revocation of the Making of a level 1 Treatment Order

> MR90E Inpatient Treatment Order level 2

> MR90H Leave of Absence

> MR90I Administration of an Episode of Emergency ECT without Patient Consent

> MR90K Patient Transport Request

> MR90L Transfer of an Involuntary Inpatient within South Australia

> MR90M Request for Approval to Transfer to an Interstate Treatment Centre

> MR90N Transfer from Another Jurisdiction to a South Australian Treatment Centre

> MR90O Revocation of a Treatment Order Optional

> MR82P Sharing Consumer Information Consent Form

> MR90F Report to the Director of the Making of a level 2 Inpatient Treatment Order

> MR90S Checklist for Procedural Requirements Statements of Rights > Community Treatment Orders

> Inpatient Treatment Orders

> Leave of Absence

> Voluntary Admissions The statements of rights are available in: Arabic, Chinese (simplified), Croatian, English, German, Greek, Hindi, Italian, Persian, Polish, Russian, Serbian, Sinhalese, Spanish, Swahili and Vietnamese.

44

Appendix V – South Australian Mental Health and Rel ated Services Appendix V provides links to service finders and listings of mental health and related services in South Australia. Emergency Mental Health Services > Mental Health Telephone Triage Service – 131 465 > Lifeline – http://www.lifeline.org.au > Suicide Call Back Service - http://www.suicidecallbackservice.org.au/ > Beyondblue – http://www.beyondblue.org.au > Kids Help Line – http://www.kidshelp.com.au/ > Mensline Australia – http://www.mensline.org.au > Your family doctor or general practitioner Public Mental Health Services > The Whitepages, under “mental health” – http://www.whitepages.com.au > National Health Services Directory – http://www.nhsd.com.au/ Private Mental Health Services > Your family doctor or general practitioner can provide treatment or refer you to a private

psychologist or psychiatrist. > The Adelaide Clinic - http://www.adelaideclinic.com.au/ Non-Government Organisation Services > Mental Health Coalition of South Australia listing – http://www.mhcsa.org.au/ Aboriginal Health Services > Aboriginal health services finder –

http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+services/aboriginal+health/aboriginal+health+services

Advocacy Services > Community Visitor Scheme – cvs@health.sa.gov.au > Office of the Public Advocate – http://www.opa.sa.gov.au > Disability Advocacy and Complaints Service of SA – http://www.dacssa.org.au/ > Multicultural Advocacy Liaison Service of SA – http://www.malssa.org.au/ Complaints Services > The Complaints Officer or Consumer Advisor of your health service > Office of the Chief Psychiatrist – ocp@health.sa.gov.au > Health and Community Services Complaints Commissioner –

http://www.hcscc.sa.gov.au Appeals > Guardianship Board of South Australia – http://www.guardianshipboard.sa.gov.au/ > District Court of South Australia – http://www.courts.sa.gov.au/OurCourts/Pages/default.aspx Legal Services > Legal Services Commission – http://www.lsc.sa.gov.au/ > The Law Society of SA – http://www.lawsocietysa.asn.au/