Mental health policy changed in the 1960s, with the idea of community care rising to the fore. Between the 1970s and the 1990s, mental institutions were gradually shut down, and community care became the dominant model, with only about 8% of mental health patients receiving inpatient care. De-institutionalisation was nearly complete, and this was seen as a victory.
Institutions were pretty awful places, and even with the best of advances in care, stables of the seriously ill herded together and kept separate from the outside world is a bloody awful idea. But the seriously ill need somewhere to go, and this is simply not provided for in the community mental health model.
First, there’s the acutely unwell. These are meant to be handled by the inpatient ward, but there aren’t enough beds. Last time I was an inpatient, I overheard the unit co-ordinator discussing with her senior staff which patients were the least unwell because she needed to free up some beds. I was let go without much of a care plan in place because I was the least unwell – but I was still not sleeping and not really well enough to be around my kids. The step-down from the ward was non-existent.
That step down from inpatient care is the respite house. It’s a safe place to be without the intense supervision of the ward, and it’s an important transition between the ward and the outside world if things aren’t completely stable yet. It’s also important as a place to go before you’re unwell enough for the ward, to try and head off that need. Hutt Valley DHB had a total of precisely three emergency respite beds, and a further three or four for planned respite, which are booked out months in advance. MidCentral has an even better collection, with not a single adult respite bed as of my last experience with them (further research has turned up funding for 2.3 adult respite beds, whatever that might mean. Sure as hell won’t mean a dedicated respite house. Other resources call respite beds ‘conceptual’). It’s the ward or fend for yourself.
So much for acute care. What about the more long-term needs? When I was in the unit I was sharing accommodation (in an acute care ward) with people who had been in there months, even years. That is most definitely not what an acute care ward is for, but where else can long-term high-needs people go? Upon the closing of the institutions, there was supposed to be sheltered accommodation created – places where the seriously unwell who cannot live independently are safe. But over the intervening years, these have either not materialised, or been shut down. This is not my area of expertise, but those I have talked to are devastated at the lack of sheltered accommodation available to people in need. It feeds the over-population of acute care wards, and the problems of homelessness, and the incidence of people unable to care for themselves living in the modern equivalent of council housing and living pretty miserable lives.
I’m not saying that returning to mental institutions is the answer. They’re not a good solution for anyone. But supported living arrangements need to be available, and they need to be available now. There are stories of psychiatric patients being released to night shelters, with promised support to the shelter never materialising. Promised support? What on earth are we doing releasing unwell people to a completely unprepared shelter, with no more than vague promises of support? It’s so wrong, and so inadequate.
“Te Ara Pai – the Stepping Stones to Wellness policy – for psychiatric patients continued a trend of reducing funding for supported accommodation houses, with some of the money redeployed towards more advocates trying to help people into a shrinking housing supply.” Policies like this are just outright ridiculous. Getting rid of housing, then funding people to help place patients in housing that doesn’t exist any more? What the hell kind of plan is that? I’m sure there is more to it than this, but from this outsider’s perspective, they are slashing a bleeding wound in the side of mental health care, and then hoping a couple of steri-strips will hold it all together. It’s not going to work.
So what do we have? Progressively aggressive community health care being applied to people for whom the community health model is completely inadequate. Progressive shuttering of safe places for these people to live. A progressive failure to cater to the needs of some of the most unwell and vulnerable in our society. Policy makers should be educated in this reality, and if they already know they should be ashamed.