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Mentalhealth.wa.gov.au

MENTAL HEALTH LAW CENTRE (WA) Inc.
ABN 40 306 626 287

Our Ref: SB NCW 572
6 March 2012
Mental Health Commission
GPO Box X2299,
Perth Business Centre WA 6847
DRAFT MENTAL HEALTH BILL 16 DECEMBER 2011
Mental Health Law Centre (WA) Inc. SUBMISSION
PHYSICAL AND DENTAL HEALTH OF INVOLUNTARY PATIENTS AND PRISONERS
We take this opportunity to make a submission on the Draft Mental Health Bill
released for public comment on 16 December 2012.
General Position
The Bill authorises a single "authorised mental health practitioner" (not
necessarily a doctor and perhaps simply an enrol ed mental health nurse with
two days training in making referrals) to assess/ examine, refer, detain and
transport a person against their wil and without their consent, to a psychiatrist
(sometimes thousands of kilometres away from the patient's home) for an
examination to decide whether or not that person requires detention
(involuntary admission to an authorised psychiatric hospital or hostel) and/or
involuntary treatment; and authorises the examining psychiatrist (who may or
may not have trained in Australia) to make an involuntary detention and/or
treatment order sometimes on the basis of a hurried five minute examination.
Mistakes and oversights happen in a busy, under-resourced system whose
priority and objective is treating a person's mental illness. Physical and dental
il health may be the underlying cause of mental il -health – such as urinary
tract infection in elderly people causing psychosis, may impede recovery
from mental illness and may be low on the agenda of mental health
96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] professionals. The WA Coroner has reported on the death of an involuntary
inpatient from the failure to physical y examine her.
Mental Health legislation is about authorising the State to detain and treat
people without their consent to protect them or others from the effects of
their mental il ness. Legislation that creates such powers must do everything it
can to protect patients against error, malpractice, mismanagement and
poor resources, however limited or rare such events might be. A criminal
conviction requires the facts to be established beyond reasonable doubt to
the satisfaction of a magistrate, judge or jury, al of whom are removed from
the charging and fact finding process, before someone can be imprisoned.
Nothing less should be available to someone with a mental il ness who the
WA government proposes to detain. Fundamental human rights and
freedoms are removed from someone civil y detained under mental health
legislation, arguably more than prisoners.
ENHANCING AND PROTECTING THE PHYSICAL AND DENTAL HEALTH OF
INVOLUNTARY PATIENTS and PRISONERS
We propose the fol owing inclusions in the Mental Health Bill: 1. A person, because of his status of involuntary patient or patient in an authorised hospital should not be at a disadvantage when it comes to accessing physical health care treatment. "Best care and treatment" must be defined in the BiIl to include accessible provision of both physical, dental and mental health care treatment to al involuntary patients and voluntary patients admitted to or present in an authorised place and declared place, and al patients on Community Treatment Orders. 2. The Bill must prescribe an integrated and holistic treatment and discharge plan, which wil ensure the continued care of voluntary and involuntary patients, can be achieved to a standard that any member of the community would expect, as fol ows: a. A General Physical Examination (GPE) must be conducted for al involuntary patients and al voluntary patients admitted or in authorised hospitals by an independent general practitioner as fol ows: i. An initial GPE must be conducted on admission, which would enable such an examination to be meaningful y conducted, within 24 hours but not later than within one week of admission. ii. The GPE conducted regularly as prescribed or at least monthly for involuntary patients detained in hospital. iii. The greater frequency of the GPE must be provided in response to needs arising from factors including: (a) The severity of the mental illness experienced by the involuntary patient; (b) The variety and quantity of psychiatric medication that has been prescribed to the patient by his or her psychiatrist; (c) The patient's medical history (diabetes etc.) and patient's physical health care needs; (d) The likely side effects of the patient's medications; (e) Signs and symptoms exhibited by the patient. b. The GPE will also include an initial and annual dental examination and follow up dental treatment as needed. The purpose of the above is to ensure that patients receiving medications directed at treating their mental il ness have the opportunity and access to a general practitioner because of the impact of the side effects such medication can have on physical health, which can be highly detrimental if not addressed promptly. Recommendation 5 recognises the importance of dental health as a part of our overal health and wel being. 3. The Bill must ensure that both the Minister and Chief psychiatrist must 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] a. Physical illness, including side effects from treatment, of involuntary and voluntary patients in authorised hospitals are met through a general physical examination and treatment by an independent general practitioner, or as referred by the GP, and not by the treating psychiatrist or other members of the treating team; b. The Minister must ensure that involuntary patients and voluntary patients in authorised hospitals can easily and equal y access timely physical health care treatment; and c. In the event that an involuntary patient is a child or a young adult, in addition, their developmental needs must be taken into consideration when deciding on treatment for their mental and /or physical illness. 4. Part 7 places a statutory duty of care upon the Minister and the Chief Psychiatrist to ensure that involuntary patients can easily access physical health care and specialist care without disadvantage. 5. Regular physical examinations would encourage patients to have normal social interactions with medical practitioners outside the mental health service. This would assist the patient to maintain and/or develop socialisation skills in readiness for their return to life outside the authorised hospital. It would also help them return to or stay on track with their lives when they return to life outside hospital. 6. The casting of an objective or third eye by an external medical practitioner responsible for the patient from outside the treatment of mental illness would promote and enhance the likelihood of a holistic medical assessment of the patient. This would, in time, improve the patient's overal health and well-being, and enhance their chance of a sustained recovery. 7. Individual patients' mental health treatment would benefit from additional non-psychiatric medical insights provided by their independent GP. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] 8. The objects of the Bill should be amended to include specific reference to meeting the physical and dental health needs of people, the subject of the Bill. 9. The Bill should require separate authorised beds for children, separate from adolescents and these beds should be resourced to treat children for all illnesses in a holistic way. 10. The Bill must provide for CTOs to be binding on prisoners and applicable in prisons – either awaiting trial or sentenced prisoners – and binding on prison authorities. 11. The Bill must be consistent with the United Nations Convention on the Rights of Persons with Disabilities, which has been ratified by the Australian government. 12. The Charter, which is included in Schedule 1 of the Bill, should be moved to be included in the Bill after the Objects to increase its strength and recognition and credibility. It should also be measured against al the relevant Conventions to which Australia is a signatory and amended accordingly (see Annexure Two for a start on this analysis). 13. Al provisions in the Bil where regard is to be had to the Charter must be couched in mandatory terms, not discretionary terms, because the terms of the Charter itself are not binding. The Charter wil be toothless otherwise. Part 3, clause 8 of the Bill must include mandatory reporting to the Chief Psychiatrist who in turn must make report in the Annual Report, when the Charter has been departed from including the reasons and decision by the CP whether or not the departure was justified. 14. The Charter has included a provision relating to physical health needs of people, the subject of the Bill. The inclusion of the word "other" is curious and inexplicable and should be removed from clause 8 of the Charter. Furthermore, the words "and dental" should be inserted after the word physical in clause 8 of the Charter. 15. Clause 59 of the Bill provides that the treating psychiatrist must report regularly to Chief Psychiatrist. While cl 59(1)(a) provides that the treating psychiatrist must report to the Chief Psychiatrist about the 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] patient's mental and physical condition, it does not and should include a medical review undertaken by an independent GP at least once a month and an annual review by a specialist physician and dentist. The opinion of an independent GP should also be taken into account when the treating psychiatrist reports to the Chief Psychiatrist. 16. Clause 106 of the Bill provides that the involuntary community patient must be examined by the supervising psychiatrist, a medical practitioner or a mental health practitioner. While cl 106(2) ensures that an involuntary patient wil be examined by a supervising psychiatrist, a mental health practitioner or a medical practitioner, it does not make mandatory a monthly check-up carried out by an independent general practitioner, or an annual examination by a physician and a dentist. Such a check-up should be mandatory and this should be expressly stated in the Bil . 17. Clause 106 should make mandatory a monthly physical check-up provided by a GP, and an annual check-up by a specialist physician and dentist, as should the terms of a CTO. The reports from these practitioners should then be provided to the treating psychiatrist. The treating psychiatrist, general practitioner and dentist should work closely to ensure that a patient's mental and physical health needs are addressed. In the course of this process, the patient should also be referred to other medical professionals such as dentists, and specialties as needed and these referrals should be attended to in a timely manner, and where a referral has been made a copy should be provided to the MHT. 18. Clause 107 of the Bill provides that the supervising psychiatrist may request a practitioner to examine an involuntary community patient. While this clause appears to be for the purpose of whether or not involuntary status should continue, or could be expanded to include examinations for physical and dental health as necessary, and not less often than certain prescribed periods. 19. Clause 148 of the Bill provides that the treatment, care and support provided to a patient must be governed as far as practicable by a treatment, support and discharge plan. Cl 148 aims to ensure that a patient is provided with a clear treatment plan to which he or she will adhere. Clause 148 must clearly prescribe that the plan is to be overseen by both a treating practitioner (as stated in cl 122) and an 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] independent GP. An independent GP would monitor the progress made in terms of a patient's physical health, while also keeping track of any harmful physical and/or dental side effects experienced by the patient in the course of receiving his or her treatment. 20. By clearly defining the roles of the treating psychiatrist and general practitioner in the treatment, support and discharge plan the approach wil be more holistic, there will be greater accountability and there will be an increased chance of a sustained recovery. This personalisation of the care plan is consistent with the Minister's objectives for people who are subject to mental health legislation. Involuntary patient status should not cause a person to be at a greater health disadvantage than if they remained a voluntary patient. Our proposed model would mean that involuntary patients would benefit from a holistic treatment plan. 21. Clause 202 of the Bil requires a physical examination of a patient admitted to an authorised hospital, which is defined at clause 423 to include various places. In our opinion clause 202 wil not remedy the problem presently faced by involuntary patients. The Bill simply gives expression to a standard of care that presently exists for admission to any hospital (although unstated in the current MH Act) for patients admitted involuntarily to authorised places, that is the accepted standard of care would require a physical examination to take place on admission. In the Centre's experience as witnessed by medical records, this obligation is not always observed and we do not understand how the statement of a requirement that already exists will resolve the physical and dental health il health currently faced by involuntary patients, especial y inpatients. There is no requirement in the Bill to obtain external independent monitoring of the physical and dental health of patients subject of the Bil . Furthermore, the Bill makes no consequences for failure to observe the mandatory requirements of clause 202, and it should, otherwise there will be little change. In our opinion, the Bill does not have the propensity to significantly improve the response to the physical and dental health needs of patients, the subject of the Bill 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected]
It is critical for the improvement of the outcomes for involuntary patients that
they receive regular physical examinations conducted by a medical
practitioner independent of the mental health services.
While the Mental Health Bill 2011 (the Bil ) attempts to address some of the
issues raised in this article, more must be done to ensure that mental y ill
involuntary patients are provided with holistic health care treatment. The Bil
does not include a mandatory regular physical check up by an independent
medical practitioner and it should.
By incorporating independent GPs into the involuntary patient procedures,
both a patient's mental and physical health problems will be addressed. This
also wil improve accountability.
Furthermore, the harmful side effects which may arise as a result of
psychiatric treatment can be more effectively treated, the chances of it
being overlooked will be reduced and mistaken aetiology and diagnoses are
likely to be remedied.
Furthermore, for example some patients are not taken out of their secure
environments every day to breathe and feel fresh air and sunlight, or
encouraged sufficiently to exercise. There should be provisions to require this.
Support for our submissions is at Annexure One to this submission and is a
journal article in draft form, which will soon be settled for submission for
publication.
Please do not hesitate to contact me to discuss this submission further.
Yours faithfully
Mental Health Law Centre (WA) Inc.
SANDRA BOULTER
Principal Solicitor
General Manager
96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] ANNEXURE ONE
Improving the quality of life of a mental health patient with the aid
of general practitioners
Sandra Boulter 1* and K.H.A Ahshiba Sultana2
aPrincipal Solicitor and General Manager of the Mental Health Law Centre (WA) Inc.; b Third
year student, Faculty of Law, Murdoch University3
Mental health and physical health are demonstrably interdependent. In Western Australia, the standard of general medical and dental care received by involuntary patients appears to fal below acceptable standards. In our experience, physical health issues are sometimes being overlooked or inadequately treated. There is a pressing need to amend mental health legislation so that al involuntary patients in authorised hospitals receive a physical examination and appropriate fol ow-up care by a general practitioner (GP) independent of the mental health service from which they are treated or the authorised hospital in which they are detained. This would go a long way in helping to improve the quality of life of people with a mental y illness and it would benefit them both in the short term and long term. Keywords : Physical health and mental health; barriers to health care;
involuntary patients; mental illness; general practitioners; duty of care.
Introduction

One way of improving and maintaining the physical health of al involuntary patients would be for them to have regular physical health examinations by a GP who is independent of the authorised hospital in which they are being held. This requirement should have been included in a new Medical Treatment Part of the Mental Health Act 1996 (WA) (the WA Act), which was recommended in the Holman Report over eight years ago. Al involuntary patients should receive an initial and annual examination by a specialist a Correspondence: Mental Health Law Centre (WA) Inc., 96-98 Parry Street Perth, Western Australia, 6000,
Australia. Email : [email protected]
2 Third year student, Faculty of Law, Murdoch University
3 The author acknowledges the research undertaken by volunteers, Kimberley Pender LLB (Hons) (Aberdeen),
Tracey Pearce, Catherine Gartner, Kas Murthy.
96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] physician and dentist, and receive prompt compliance with expert referrals from the treating psychiatrist or GP responsible for the patient. Our three primary submissions are: 1. Regular physical examinations would encourage patients to have normal social interactions with medical practitioners outside the mental health service. This would assist the patient to maintain and/or develop socialisation skills in readiness for their return to life outside the authorised hospital. It would also help them return to or stay on track with their lives when they return to life outside hospital. 2. The casting of an objective or third eye by an external medical practitioner responsible for the patient from outside the treatment of mental illness would promote and enhance the likelihood of a holistic medical assessment of the patient. This would, in time, improve the patient's overal health and well-being, and enhance their chance of a sustained recovery. 3. Individual patients' mental health treatment would benefit from additional non-psychiatric medical insights provided by their independent GP. It is arguable that a program, which incorporates accepted standards of
physical health care, would measurably promote and enhance the quality
and standard of care of patients in authorised hospitals, both individually and
as an identifiable community of patients.

The Holman Report
In 2003, the Holman Reporti formal y recognised and advised the WA government about a number of deficiencies in WA mental health legislation. It recommended at 5.9 that:  Part 5 Division 6 of the WA Act (entitled Other treatment, involuntary patients and mentally impaired accused) be renamed Medical Treatment;  A new section be added to this Part to require al persons admitted to al authorised hospitals to have documented in their 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] case record the results of a complete medical assessment fol owing reception into that service.ii The Government Report accepted this and further commented: iii The document "Duty to Care" clearly identified that health services can improve their attention to the physical needs and illnesses of persons with mental illness. The high rates of certain physical illnesses in persons with mental illness require a comprehensive and considered approach. This new section is part of that drive towards ensuring that the physical needs of persons with mental illness are fully met. Rates of physical illness in people who have a mental illness
People affected by mental illness have higher levels of morbidity and
mortality than found in the general WA population. They experience poorer
general health and higher rates of death from a range of causes, including
suicide. These conditions are significant in terms of prevalence and disease
burden, and have far-reaching impacts for families, carers and others in the
community.iv Providing improved physical health care for people suffering
from mental il ness is much discussed throughout the medical community. It is
general y accepted that there is a clear link between physical and mental
health, and that inequalities within health care systems mean that mental y ill
patients are not receiving adequate physical health care.

Statistical evidence confirms the high rates of physical il ness in persons with a
mental illness. The National Survey of Mental Health and Wel being carried
out by the Australian Bureau of Statistics (ABS) in 2007 (the Survey) showed
that of the 3,197,800 Australians aged 16-85 years who suffered from mental
disorders, 58.7% also suffered from a physical illness. The Survey also
highlighted that of the 16 million Australians aged 16 -85 years, approximately
12% had both a mental disorder and a physical illness, and approximately
8.5% had two or more mental health events in a 12 month period.v In 2004 -
05 a survey conducted by the ABS revealed that persons with a mental illness
aged 15 and above, were three times more likely to report poor physical
health than those without diagnosed mental or behavioural disorders.vi
96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Health-Risk Behaviour Health-Risk behaviour may occur because people with a mental il ness often demonstrate behaviours that carry high health risks such as smoking, alcohol, substance abuse, poor hygiene, poor diet and lack of exercise, thereby putting them at a particularly higher risk of developing conditions such as diabetes, heart disease, obesity, anaemia, respiratory disorders, poor dental health and nutritional deficiencies. Mental y ill persons also have an increased risk of contracting Hepatitis and HIV infections from intravenous drug use and high risk sexual behaviours.vii Research conducted by the University of Western Australia showed that 46% of people with mental health problems smoke and that they smoke 44% of al cigarettes consumed. Such high–risk behaviours make people with a mental illness more susceptible to physical health problems.ix There is emerging evidence that people with a serious mental il ness can stop smoking, lose weight and be more physical y active if interventions and lifestyle programs are tailored to overcome the neurological, cognitive, behavioral and social deficits associated with a serious mental illness.x Improvement in their health could be slowly achieved with the engagement of GPs independent of the mental health service dedicated to each patient through a holistic treatment program. Oral Health People with a mental il ness are more susceptible to poor dental health. If
overlooked this can have severe repercussions for a patient general y and
their physical health in particular.

Oral and systemic side effects of medications used in mental illness treatment
are common and detrimental to the overall oral health of these patients.
Antipsychotics, antidepressants and mood stabilisers can al cause
xerostomia, a condition which results in the reduction of salivary flow. This
changes the oral environment and leads to caries, gingivitis and other
diseases.xi Dilantin, prescribed for mental illness treatment, can result in
gingival hyperplasia, a condition that causes the patient's gums to grow,
resulting in the appearance of smal er teeth and potential dental problems. xii
96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Problems associated with gingival hyperplasia may be minimised by regular dental care and good oral hygiene. Pharmaceutical treatments can have a significant adverse impact on oral
health by increasing dental caries, periodontal disease and oral infections.
Oral health is fundamental to overal health, wel being and quality of life.xii A healthy mouth enables a person to eat, speak and socialise without pain, discomfort or embarrassment.xiv Good oral health also contributes to physical and mental well-being while improving social interactions and self-esteem.xv This enhances socialising and improving the likelihood of a successful return to living a normal life. Poor oral health, dental care or treatment may further compromise physical and mental medical problems associated with alcohol abuse, drug addiction, smoking, stress, eating disorders as wel as prescribed medication. A large number of mental y ill patients al over the world suffer from poor oral and general health. This issue is recognised in India, where mental y ill patients are offered dental treatment and a regular dental check-up. These dental check-ups are conducted twice a year to ensure that the dental needs for people with a mental il ness are well taken care of and to prevent future oral and systemic complications.xvi In India, great care is taken to ensure that people with a mental illness are provided good oral health care and treatment. Uncooperative patients are referred to the Higher Centre Government Dental Col ege Hospital Chennai and the patient undergoes dental treatment such as scaling, dental fil ing and tooth extractions in a single admission after which they are sent back to their rehabilitation centre.xvi There is a close collaboration between the treating psychiatrist and the dentist regarding the patient's mental and general health status. This co-operation to facilitate dental treatment, and manage any possible side effects and interactions with general and dental medication, are discussed because it helps decide the form of anaesthesia the patient receives.xvi i Close co-operation between the psychiatrist and the dentist is important to facilitate the best mode of treatment offered to the mental y il patient.xix The treating psychiatrist may alter the daily medication for the patient before dental procedures are carried out. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Treating Physical Illness A study of 100 people diagnosed with a mental illness saw a reduction of 60% of their mental health problems when the physical health of this group was ful y investigated and their physical health problems were treated.xx It appears that one of the reasons for this is that people with a mental illness experience higher levels of stress than the average person. This reduces the power of their immune system, thus making them more susceptible to diseases. People with a mental il ness require an active and holistic approach to their treatment because physical health and mental health are interdependent. The prevalence of untreated physical illness amongst people with a mental il ness is closely linked to their life expectancy which is 18-20 years less than the general populationxxi. A recent study by the University of Western Australia examined the health experience of 240,000 West Australians who had used mental health services during 1980 – 1998 (the Study). The Study showed that people suffering from a mental illness are more vulnerable to contracting a physical illness.xxi The Study also noted that the number of deaths from physical il ness in people with a mental il ness far exceeds the number of admissions into hospital for those same illnesses from the wider population. These statistics highlight the urgent need for better detection and treatment of physical il ness in people with a mental illness.xxi i How can this be addressed?
The Mental Health Council of Australia recognised the strong link between mental and physical health in 2010 as follows: "good physical health has been identified as a key component to maintaining good mental health as the relationship between physical health and mental health is closely interlinked. The relationship includes the effects that a person's mental illness might have on their physical health, meaning how mental illness might impact on the body's physiology, or whether a physical illness is either causing or exacerbating a mental illness."xxiv 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] "There is an urgent need for the mental health profession to address stigma within mental health services as well as recognising the specific physical health needs of people with mental illness."xxv
This important nexus between physical and mental health shows that they
should not be seen as mutually exclusive. With improved physical health,xxvi
we can expect to see improvements in the mental health of a person, and
through recovery from a mental illness, we can often see an enhancement in
their physical wellbeing. Despite these facts and wide recognition of them,
people with a mental illness continue to encounter higher levels of difficulty in
accessing appropriate health services and often do not receive the same
standard of care for their physical health as does the rest of the
community.xxvii Part of the solution is statutory reform.
Barriers to Health Care

A patient with a mental illness and a physical illness or complaint faces more
barriers to accessing other health care services than the average physical y ill
patient. Three relevant factors include patient, system-level and provider
barriers.xxvii Behavioural factors can lead to poor compliance, unreliable
attendance and late cancel ations of appointments. Such behaviour is often
a source of frustration, and sometimes bewilderment, resentment, and may
lead to some patients expressing hostility toward staff members during the
delivery of medical service,xxix or vice versa. An authorxxx has experienced
the refusal of a private physician to see her client in his private consulting
rooms because of the client's mental illness, which it is noted posed no safety
risk to others.

Patient related barriers

Patient related factors are said to include, "health risk factors and lifestyle factors", and range from a patient's attitude and feelings to addictions such as smoking or drinking. There is often a reluctance to treat patients with severe on going addiction. These addictions themselves may not be addressed in patients already being treated for mental illness. One of the reasons for this is that it requires more time and effort. Patients in authorised hospitals with a mental illness and complex needs require the service of specialised targeted programs, clinics, and facilities staffed by personnel with advanced training and experience. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] A third perspective from a general practitioner, independent of the mental health service, is critical for providing a holistic approach to the care of involuntary patients. The wil ingness of the person with a serious mental illness to accept treatment can depend on factors including mood, motivation, self-esteem, ability to think and behave logical y, access, accept and understand the treatment plan, and ability to cooperate with treatment. Patients with a mental illness may have less ability or a lack of capacity or insight to accept treatment for their physical health. An unmotivated patient who feels worthless may not effectively communicate their health concerns and needs. People with mental il ness often have difficulty in communicating signs or symptoms of a physical illness and in some cases may not even be aware of their physical illness. This makes them less likely to seek treatment. Even if they do identify the need for treatment, the ability to accept treatment depends on many factors. Untreated physical health problems can create further social barriers for involuntary patients who are already marginalised by their mental illnessxxxi, and the stigma associated with it. System-level barriers System-level barriers may prevent a person suffering from mental illness receiving medical care. These barriers include lack of resources, confusion and uncertainty about who is responsible for what type of care, and a lack of sensible cohesion between mental and physical health care, or simply the lack of a well-informed articulate advocate acting in the patients' best interests. It is often the case that physical and mental, health and wellbeing are fragmented between different areas of health care service, and that these areas do not always communicate effectively with each other. This can be compounded by lack of continuity of care between and within services. Mental health care and treatment tend to come under a siloed area of care, and are thus targeted separately from physical health. Often mental health treatment is carried out in specialist psychiatric centres and hospitals with limited expertise and/or facilities and staff to identify and respond to the physical health needs of patients. Even when training of mental health professionals has included training for treatment of physical il ness, it is likely that their skills atrophy with lack of practice. In such scenarios, the patient 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] may not have adequate holistic treatment, which responds to their physical health needs. This may be exacerbated by lack of communication between mental health professionals in these institutions, and general physicians and other specialists. Treating one problem at a time may be an easier approach in the short term. However, treating someone only for their mental illness may significantly overshadow the need for diagnosis and treatment of the symptoms of physical diseases, or the physical side effects of their treatment for mental il ness. Mental health specialist staff may lack physical health skil s; and physical health specialist staff may not understand mental illness, care and treatment. This can result in patients not receiving the medication they need for mental il ness while in hospital receiving treatment for a physical illness, and vice versa. xxxii This is particularly exacerbated by an admission to a prison where medications prescribed for treatment of mental or physical il ness are not necessarily continued in a timely manner or at al , as reported to the authorxxxii . Provider level issues Provider level issues include factors such as the effects of stigma, time and resource constraints, and the possibility of regarding physical complaints as psycho-somatic symptoms.xxxiv People with mental illness who do seek medical attention for physical health issues may be unable to access the correct help because their pressing and apparent mental health illness overshadows signs and symptoms of physical il ness. An example can be seen when ‘physicians report difficulty in assessing sensory functioning in psychotic patients. For example, doctors may have trouble determining if a patient's complaint of "hearing noises" represents tinnitus or an auditory hallucination.'xxxv Patients' complaints may not be taken seriously because their symptoms are responded to in terms of their mental illness and treatment, rather than their physical health and wellbeing, perhaps because of an assumption that one should take priority over the other.xxxvi 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Mental health services for people with a mental illness focus on treating the mental illness. Statistics suggest that health problems may be overlooked, if these are not specifical y and clearly part of the mental il ness, and the treatment plan. The evidence suggests that mental health and physical health are interdependent. Psychiatrists are specialists in one area of practice and because of this may overlook or neglect diagnosing or treating other il ness of patients in psychiatric hospitals, which in turn add to or exacerbate the illness and suffering of the patient.xxxvi The impact of System-Level Barriers and Provider Level Issues on involuntary patients The Coroner's Report, which recorded the investigation into death Ref No: 12/09 made recommendations that in the case of psychiatric involuntary patients, a physical examination should be conducted at a time when those patients have settled to an extent, which would enable such an examination to be meaningfully conducted.xxxvi i Record of Investigation into Death: Ref No: 12/09 Ms V (in her 40s) was admitted as an involuntary patient to a regional hospital psychiatric facility following relapse of her schizo-affective disorder. She was an involuntary patient within the meaning of the Mental Health Act 1996, and was also a person "held in care" for the purposes of the Coroner's Act 1996. Ms V had an extensive psychiatric history and had been admitted to the same mental health unit for long periods on previous occasions. She had a history of constipation and an undiagnosed episode of collapse associated with vomiting black fluid three weeks before her death. During her last admission her constipation worsened. Eleven days after admission she complained of abdominal discomfort, then vomited faecal material. She was examined and found to be tachycardic and hypotensive, and she also suffered from a distended abdomen. A diagnosis of acute bowel obstruction was made and Ms V was transferred to a general ward. Chest and abdominal x-rays were taken, which showed reduced lung capacity and impacted faeces. Her failure to respond to resuscitation resulted in her death. The Coroner's Inquest revealed that Ms V:  died as a result of aspiration resulting from a bowel obstruction due to 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected]  was being administered a cocktail of medications capable of causing constipation including Chlorpromazine, Olanzapine, Benztropine, Lamotrigine and Ferrograd C;  complained of her constipation on prior occasions although these complaints were not recorded;  had an abdomen that appeared distended and the extent of the distension would have been obvious on examination;  had not been physically examined at any stage during her admission to hospital because of uncertainty about the role of attending physicians in a shared care The medical examination by the Chief Forensic Pathologist showed dilation of the large intestine due to impaction of faeces. Ms V's lungs were congested with aspirated vomit in the airways. The report describing his examination of Ms V's gastrointestinal system noted that the whole of the large intestine was dilated up to 12-15cm in diameter and the total weight of the large intestine faeces was 2,450g. It would appear obvious (from the level of faecal impaction) that if, at any stage during her period of involuntary admission, Ms V had been competently physical y examined, her gross state of constipation would have been discovered and action would have been taken to remedy the situation. Evidence at the inquest revealed that during her period of admission, Ms V was not ever physically examined by either her admitting doctor or by the psychiatric team. There were no instructions given by the medical staff to the nurses to monitor her The admitting doctor claimed that Ms VG was under the exclusive management of the doctors on the ward and so all decisions relating to her were the responsibility of the psychiatric team. The medical practitioner who treated Ms VG before her death gave evidence that his understanding of the position was similar to that of the admitting doctor, which was that if a patient of his was admitted as an involuntary patient to the hospital he would endeavour to see the patient but not necessarily within a short time after the 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] admission, to discuss how the patient "might be going" but that visit would not include a physical examination. This is because under the current system, there is no statutory obligation for a regular physical examination by a GP. Although the hospital had a "shared care model" which made the general practitioner responsible for the on-going medical care of the involuntary patient, the Policy and Procedure manual did not reflect this position until it was endorsed in May 2008. There was no clear division of duties between the psychiatric team and the general practitioner. The fol owing recommendations were in the Coroner's report and are relevant to this submission: 1. In the case of psychiatric involuntary patients a physical examination is conducted at a time when those patients have settled to the extent which would enable such an examination to be meaningfully conducted; and 2. The role of the general practitioner should be clearly defined and any steps taken to change those policies (of the hospital) should be communicated to the practitioner. These two recommendations are directed to tackling system-level and provider-level barriers experienced by an involuntary patient when it comes to accessing physical health care treatment. The lack of a clear statutory provision, which prescribes regular physical examination by the independent general practitioner, was a contributing factor in the confusion over the duties of the medical practitioners and the preventable death of the deceasedxxxix4. An article published in the Sydney Morning Herald further highlights problems associated with the consumption of anti-psychotics. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Harmful Side Effects of Anti-Psychotics Julio is a 23 year old male. At age 21 he was diagnosed with bipolar disorder. However, his physical health was compromised by the consumption of anti- psychotics, which resulted in him gaining 20 kilograms in 6 months. Dr Jackie Curtis, the clinical leader at the Bondi Centre, tells us that someone with schizophrenia is 10 times more likely to die from cardiovascular disease than suicide. With the help of an independent general practitioner, young patients can be given drug treatments such as the diabetes drug metformin or cholesterol-treating statins more commonly associated with much older people. They can also be provided with exercise and diet advice. Treating the side effects of psychiatric medication is just as important as treating the mental il ness itself.xl Case studies highlight the risks associated with the consumption of psychiatric
medication, which when overlooked, may be harmful and even fatal.
Independent oversight and treatment by a general practitioner would be
useful in managing and reducing the adverse impact of poor physical health
on patient with a mental illness.
Specialist care

Having established that mental y il patients are more likely to suffer from
physical illnesses and that there is a strong link between a patient's physical
health and mental health, and indeed life, the need for specialist physical
health care is a crucial element of any holistic treatment planxli.
Specialist care will help in meeting the needs of adults and older people with
moderate to severe mental health problems. This was one reform area
adopted in Victoria. The model adopted in Victoria is based on a supported
decision making model to help minimise involuntary treatment, reduce the
use of restrictive practices and improve recovery outcomes.
Case Study which highlights the need for a more holistic treatment program 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] ‘Rita' (aged 29) was admitted as an involuntary patient in 2007 to a Perth based authorised hospital and she remained an involuntary patient in a locked ward until 2010 when she was transferred to another psychiatric hospital where she remains today. She suffers from multiple physical il nesses. She was diagnosed with schizophrenia and given depot of haloperidol among other anti-psychotics. At the time of her admission, she weighed 180 kg. Rita has diabetes mellitus, cellulitis in her right leg, has had a left-sided oophorectomy to polycystic ovarian syndrome (POS), was morbidly obese (180kg) and she suffered from eczema and anaemia. Rita's POS Syndrome and menorrhagia, iron deficient anaemia and diabetes mellitus suggested to the second opinion external psychiatrist an hormonal imbalance and possible tumour in the pituitary gland could be affecting her ability to control her emotions and mental wel -being. This factor was apparently overlooked by the treating team who put her emotional outbursts down to aggression and who frequently placed her in seclusion. The treating team did not consider it necessary for an Endocrinologist to look at Rita's POS to provide them with advice on how to treat Rita's condition. When requested to do so, Rita's legal team were told that there was no acute clinical reasons for doing so. Rita also suffers from Chronic Urinary Tract Infections (UTI) and urinary incontinence. While the UTI was treated with antibiotics, the mental health service decided that her incontinence was deliberate misconduct by Rita, rather than something over which she had no control. She continues to suffer from incontinence and her medical notes reflect the fact that she is often "malodourous and incontinent of urine". The medical notes say, "when she requests Pads, direct her to the toilet". She has not been referred to any specialist who might find that Rita's behaviour was not misbehaviour, and then treat her condition. When Rita is not given Incontinence Pads, she tends to soil furniture or leave a trail of urine wherever she walks. Rita's morbid obesity and drive to eat copious amounts of food was not investigated so that a medical condition that might explain her behaviour could be ruled out. Instead a psychiatric diagnosis of Eating Disorder Not Otherwise Specified (EDNOS) was made by the treating psychiatrist. As an involuntary patient, the treating team could impose the harshest of treatment regimes on her by depriving her of food in circumstances where the psychiatric diagnosis may or may not be correct. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Before being made an involuntary patient in a locked ward, Rita had seen a Consultant General Physician and was admitted to a general hospital in 2006 for treatment. There were no follow up appointments with the physician once she became an involuntary patient in 2007, despite the fact that Rita's morbid obesity and drive to eat copious amounts of food was not investigated to rule out a medical condition, and which might have explained her behaviour. In the meantime, Rita cried with hunger during many of her waking hours. Treatment would have been different if Rita was not an involuntary patient If Rita was not an involuntary patient in a psychiatric hospital and had attended her GP on a regular basis with symptoms of POS (hirsuitism, pigmentation, gross obesity) and menorrhagia, there is little doubt that a referral to an appropriate specialist would have been made and she would have been placed under the specialist care of an Endocrinologist. If Rita was not an involuntary patient and saw her GP complaining about incontinence and UTI's, there is little doubt that she would have been referred to an urologist, incontinence physiotherapist and incontinence nurse to assist her. She would have been in a position to provide herself with her own Pads for her condition. As to Rita's weight gain, the lack of an independent medical practitioner looking at her physical condition resulted in no one ruling out non-psychiatric medical reasons that could explain her behaviour. For example, could her appetite and weight-gain have been caused by the large doses of Haloperidol that she was subjected to without her consent? It is wel known that anti-psychotic medications can cause metabolic syndrome, which can lead to obesity. POS syndrome is also associated with appetite increase and weight gain. Also not considered was Rita's childhood background. The treating team had never taken a history from Rita about her childhood nor spoken to either of her parents about her childhood. If Rita was not an involuntary patient in hospital and attended her GP for persistent cel ulitis, she would have been referred to an appropriate specialist to look after this physical il ness and reduce her suffering. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Rita's treatment highlights the need for a holistic and specialised treatment program for involuntary patients. It also shows us that people with a mental il ness who are involuntary patients are at a significant disadvantage when it comes to accessing specialist treatment, which is crucial for their wellbeing, treatment and recovery. Ordering involuntary patient status should not cause a person to be at a greater disadvantage than if they remained a voluntary patient. It also emphasises the need for regular physical examinations and the need for the objective third eye of an independent GP who is looking at the involuntary patient afresh outside the terms of a patient's mental il ness and outside the mental health services. This would enhance the likelihood of a holistic medical management of the patient's needs. Compulsory treatment and restrictive interventions People with a mental il ness must be provided with a holistic treatment plan, which takes into account both their physical health and mental health needs, and includes consultation with relevant family carers. It is instructive to review Victoria's law reform proposals. Possible areas of reform based on the Victorian Mental Health Reform Strategy 2009–2019 Implementation Plan 2009–2011 include: Minimise the use of restrictive interventions This can be achieved by introducing a revised series of orders for compulsory treatment, by improving the regulation of restrictive interventions and by providing better safeguards for people subject to compulsory orders. Improve, monitor and promote, care, wellbeing and rights This can be achieved by establishing a clear process to deal with complaints and monitor service system improvements. The local complaints management process can also be improved so that both patients and their carers understand all their relevant rights. Increase patient participation in decisions related to their treatment and care 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] This can be achieved by embedding the principles of supported decision making in statutory obligations, and core practice, through facilitating information sharing and engagement with carers, family and/or friends in accordance with consumer preferences and rights to privacy, where appropriate. Improve responsiveness to the specific needs of patients There needs to be close col aboration with health services to systematical y improve holistic medical care to ensure responsiveness to the needs of diverse population groups. There needs to be strong support for clients with unremitting and severe symptoms of mental il ness and high-level psychiatric disability Public specialist mental health services should also be improved to manage the health risks associated with this client group. A new approach must be adopted for people with severe mental illness and multiple needs, to improve their access to the range of health and social support services. New guidelines must be introduced to improve information sharing between clinical services and Psychiatric Disability Rehabilitation and Support Services (PDRSS) to improve continuity of care, better manage risk and to support recovery outcomes for shared clients. This wil ensure a more holistic treatment plan for mental y ill patients. There needs to be consistent best practice across mental health and drug treatment services to support clients with mental health, alcohol and drug Significant numbers of people with a mental y illness have alcohol and drug addictions. There should be an on-going up to date development of education and training materials for staff in the mental health systems about this. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] There needs to be better access to high quality mental health treatment and care for people with moderate to severe mental illness who are social y, economical y or geographically disadvantaged This can be achieved by working with specialist mental health services to target some of their capacity to people with severe mental illness, psychiatric disability and substance misuse problems living in pension-level supported residential services. A service model can be developed for a new tier of specialist mental health treatment targeted to people with moderate to severe mental illness who face socio-economic disadvantage. Reduce preventable physical health problems among people with mental Support services can be offered in metropolitan regions to improve access to primary health care services and this wil help in effectively managing clients with physical health problems and a mental illness. Specialist mental health clinicians should play a role in promoting positive health behaviour; identifying health problems early and signposting clients to appropriate physical health care. There should also be a specific program put in place that targets physical health problems, which are commonly experienced by patients with a serious mental illness. Physical health care must be a core element and statutory requirement in the involuntary patient's mental health treatment and care plans. Clinicians must be trained in the routine monitoring of physical health conditions. There must be a strong referral system pathway to primary health services for people with a mental il ness. The refusal of some specialist services to treat people with complex comorbid disabilities creates significant service gaps, and such patients are often shifted between mental health services and other specialist services without receiving effective treatment from either.xli Case Study: An Adolescent Between a Rock and a Hard Place
Alice is fourteen years old. She suffers from severe anorexia nervosa and weighs approximately 42 kilograms. She is an intelligent and articulate young girl. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Alice came to the attention of the Mental Health Services because she suffers from schizophrenia and depression, and had threatened suicide. Alice was taken to an Adolescent Unit of an authorised hospital and detained there as an involuntary patient. The Adolescent Unit does not specialise in the treatment of anorexia nervosa. So while at the Adolescent Unit, Alice was treated for depression and for schizophrenia, but her eating disorder was not treated by specialists. Her physical health was severely compromised. Alice's mother believed that she would die if left at the Adolescent Unit because of the lack of expertise in the treatment of patients with anorexia nervosa. Alice's mother was very concerned about Alice remaining at the Adolescent Unit and approached the Mental Health Law Centre to assist. She wanted Alice to be transferred to the children's hospital where a psychiatrist specialising in anorexia nervosa was available to treat Alice. At that hospital there are only 12 beds available for children with psychiatric il nesses, including eating disorders, but it is not an authorised hospital. This means that it is not authorised under the Mental Health Act 1996 (WA) (the Mental Health Act) to detain or hold involuntary patients. While the WA Act makes provision for transfer of a patient from one authorised hospital to another authorised hospital, there is no other authorised adolescent hospital than the unit in which Alice found herself. Alice's mother's repeated pleas to the treating psychiatrist at the Adolescent Unit led to an order that Alice be put on a leave of absence to PMH, which accomplished the effective release of Alice to PMH for the specialised care she urgently needed. While on leave as an inpatient at the children's hospital, Alice was scheduled to have a Mental Health Review Board review of her involuntary status. Her mother's fear for the welfare of Alice was further fuel ed by the fact that Alice had frequently told her that she was going to run away from the general hospital. If Alice had run away she would have been be col ected by the police and returned to the Adolescent Unit, not the children's hospital. An involuntary patient is either detained 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] at an authorised hospital or released into the community on a Community Treatment Order (CTO). The Adolescent Unit could not make a CTO for Alice with a condition to have Alice stay at the children's hospital because this was not a lawful option under the WA Act. Alice could be made a voluntary patient or have her detention cancel ed as an involuntary patient. The psychiatric report from the children's hospital psychiatrist supported the continuation of Alice's involuntary status. Alice's statutory review was required by the WA Act to have been arranged within 28 days of her previous review. Because of a clerical error the notification form was not provided by the Adolescent Unit within time and her review then occurred wel after the statutory 28 days. There were limited options available to Alice at the Mental Health Review Board Alice's case highlights the lack of interaction between agencies treating physical il nesses and agencies treating mental il nesses, and the inability of the system to deal with this type of comorbidity in one place. An amendment to the Mental Health Act should be made to enable a young girl like Alice to be released into a supervised environment, half way between detention in an authorised hospital and release on Community Treatment Order, such as a condition of a CTO being authorised to be to remain in a hospital. Certainly the children's hospital should have authorised beds for patients such as Alice. Furthermore, there should be authorised hospital beds for children in WA, which can provide exclusively the best care for children with eating disorders combined with mental health illness, when the eating disorder is a risk to their safety and the safety of others. For children and young people, mental health is profound in its importance, not only because it is the key to a rich enjoyment of childhood and adolescence, but also because it provides the foundation for a resilient and mental y healthy adulthood. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Mental health is an essential component of wel being: good mental health means that young people are more likely to have fulfil ing relationships, adapt to change and cope with adversity.xli i On the other hand, poor mental health in childhood and adolescence is associated with many poor childhood outcomes such as lower educational achievement, increased likelihood of smoking, alcohol and drug use, and poor social skil s and poor physical health.xliv Poorly drafted mental health laws and/or poor mental health policy sitting behind mental heal laws, can adversely impact the well-being of children and young people. It is imperative that the specific interests and needs of children and young people are taken into account in the formulation of mental health laws. The Report of the Inquiry into the Mental Health and Wellbeing of Children and Young People in Western Australia emphasises that any reform of the WA Act should be mindful of the specific needs of children and young people, and should reflect the fol owing the key principles:xlv 1. The best interests of the child shall be a primary considerationxlvi; 2. That a child or young person should have the right and opportunity to be heard in relation to his or her assessment, treatment and placement and the child's views should be taken into account in accordance with his or her age and maturity; 3. The family and/or carers of a child should have a right to be heard and involved in the care and treatment of a child, unless such involvement is not in the best interests of the child, which is to be measured only in prescribed circumstances; and 4. That mental health laws recognise the special needs of children and young people such as including consultations with special child psychologists and psychiatrists, and the creation of specialist mental health facilities; and the need to ensure that children and young people maintain involvement in education, training and recreation. It is also crucial that the differences between children and adults are recognised by the law when it comes to providing treatment for the young il patients with a mental il ness. Western Australia has one of the highest numbers of young people in juvenile detention in Australiaxlvii and has the highest rate of over-representation of Aboriginal young people in detention. Although there is no accurate data available, it is estimated that a high number of children and young people in detention have mental health problems and that the proportion of children in 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] custody with mental health issues significantly exceeds their numbers in the general population.xlvii The Inspector of Custodial Services estimates that at any given time up to 50% of the children and young people in custody could be experiencing mental health issues that are impacting on their safety or wel being.xlix It is important that the mental health of children and young people is addressed. There must be youth services to transition young people into adult mental health services. The current transition, or lack thereof, interrupts recovery and encourages lack of continuity of treatment and the transition to adult mental health services at 18 can be very frightening for a young adult with a mental il ness.l Thus, it is important that children and young people have access to a health care system that meets their individual needs. Both the Children's Guardian (NSW) and the Royal Australian and New Zealand Col ege of Psychiatrists (WA) (RANZCP) submitted to the inquiry that children and young people, both when in care and when transitioning from care, require timely and responsive access to assessments and services that meet their needs.li The Children's Guardian (NSW) listed the fol owing as requirements: "… to have a multi-modal mental health assessments ; to have timely access to multi-disciplinary teams that are competent and sensitive to meeting the needs ; to have coordinated health care and service pathways that facilitate equitable access and to experience interventions that are culturally appropriate, that enables their participation and that of their carers and where appropriate their parents"lii Such a model will aid in addressing the mental health issues experienced by children and young adults and will also al ow for early intervention. Most importantly having access to a multi-disciplinary team would mean that the child or young adult wil benefit from an holistic treatment program of continuing care. Such a model has been adopted in South Australia and this is reflected in legislation. Section 7(1)(e) of the Mental Health Act 2009 (SA) requires that children and young persons are cared for and treated separately from other patients, as necessary, to enable the care and treatment to be tailored to their different developmental stages.liii Hence, that legislation recognises that 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] mental health laws ought to reflect the special medical care that is required when it comes to treating children and young people. Childhood is a most critical stage in human development. Research from fields including neuroscience, child development and economics provide evidence of how experiences during childhood and youth can influence a range of outcomes later in life.liv At an initial assessment of a child or adolescent client, the physical examination should include developmental assessment and specific issues such as screening for sensory deficit in developmental delay. It is important that doctors and health workers are aware of potential issues, such as physical or sexual abuse, and remain alert for any physical ill health, signs and symptoms.lv This could be achieved by the requirement for a monthly physical health check up by a GP of children being treated for a mental illness. It is important to note that adult-focused service does not always acknowledge or provide for the needs of the child or young person. Appropriate emphasis must be placed on providing programs and services to adequately meet the identified mental health needs of children and young people. lvi An effective mental health system for children and young people requires more than legislative recognition of the rights and interests of children and young people. It also requires adequate resources to ensure appropriate services are available for children and young people in the community and in custodial settings.lvii Surveys of children and young people's mental health reveal the extent of need. Research shows that the longer we leave the intervention, the more difficult it is to make a positive difference. lvii The 1998 Western Australian Child Health Study found 18% of surveyed 4–16 year olds had a mental health problem,lix a national survey in 2000 identified 14% of 4–17 year olds had mental health problemslx and more recently the Western Australian Aboriginal Child Health Survey (2005) identified 24% of Aboriginal and 15% of non-Aboriginal children as being at risk of emotional or behavioural problems. It can reasonably be assumed that, like adults, a child's mental health and well-being is affected by the state of their physical health and vice versa, but added to this is the third factor of developmental impacts on children with a mental illness. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Prison Services in WA In prisons, the lack of adequate mental health service providers appears to be an issue. While some prison officers have some training in the recognition of mental illness, we understand that this is not the case in al prisons. For example, in Casuarina Prison, custodial staff reported that they had not received training about the way in which mental health disorders or any other condition including intellectual disability, autism, acquired brain injury, and medication side effects can cause behavioral problems.lxi Hence, custodial officers might be inept in recognising signs and symptoms of a prisoner's il ness, and mistake poor behavior for something that requires discipline rather than treatment. In Boronia prison, the medical attention available in relation to mental health treatment is limited. A GP visits Boronia every week for 3 hours and residents are booked into one of the 15 minute appointment timeslots. If any mental health service is required by the prisoner, she is referred to services in the community. lxii In Albany Regional Prison despite 30% of prisoners having a documented psychiatric diagnosis, the prison was only visited 2 days per month by a fly-in fly-out psychiatrist. While there may be a co-morbidity nurse, there needs to be consistent expert psychiatric input into an integrated service. These statistics highlight the inadequacy of mental health care in our prison system.lxii Convention
The United Nations Convention on the Rights of Persons with Disabilities (Convention) commenced operation on 3 May 2008. It was ratified by the Australian Government on 17 July 2008. Several of the provisions contained of the Convention on the Rights of People with Disabilities are mirrored in Australian law through the Disability Discrimination Act 1992 (Cth). Article 1 of the Convention provides that ‘persons with disabilities' includes:lxiv "those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] full and effective participation in society on an equal basis with others". The purpose of the Convention is to, "promote, protect and ensure the ful and equal enjoyment of al human rights and fundamental freedoms by al persons with disabilities (including mental il ness), and to promote respect for their inherent dignity". As outlined above, a patient with a mental illness faces more barriers to accessing other health care services than the average physical y ill patient. The Convention recognises that patients with a mental illness are at a greater disadvantage when it comes to accessing medical facilities and treatment. Article 25 requires the signatories to the Convention take al appropriate measures to ensure that mental y ill patients can access the same type of medical treatment as other member of society. Article 25 of the Convention provides that:lxv "States Parties recognize that persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability. State Parties shall take all appropriate measures to ensure access for persons with disabilities to health services that are gender-sensitive, including health-related rehabilitation. In particular, States Parties shall: Provide persons with disabilities with the same range, quality and standard of free or affordable health care and programmes as provided to other persons, including in the area of sexual and reproductive health and population-based public health programmes; Provide those health services needed by persons with disabilities specifically because of their disabilities, including early identification and intervention as appropriate, and services designed to minimize and prevent further disabilities, including among children and older persons; Provide these health services as close as possible to people's own communities, including in rural areas; 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Require health professionals to provide care of the same quality to persons with disabilities as to others, including on the basis of free and informed consent by, inter alia, raising awareness of the human rights, dignity, autonomy and needs of persons with disabilities through training and the promulgation of ethical standards for public and private health care; Prohibit discrimination against persons with disabilities in the provision of health insurance, and life insurance where such insurance is permitted by national law, which shall be provided in a fair and reasonable manner; Prevent discriminatory denial of health care or health services or food and fluids on the basis of disability." Legislation: How are other jurisdictions addressing this issue?

Australian Jurisdictions
Western Australia fal s behind other Australian jurisdictions in statutory
recognition of the importance of the physical health of mental health
patients.
The Mental Health Act 2009 (SA) has a guiding principle that there should be
regular medical examination of every patient's mental and physical health,
and a regular medical review of any order applying to the patient.lxvi
The Mental Health Act 1986 (Vic) specifical y requires every patient to be
examined at least once a year regarding their mental and general health.lxvi
The Mental Health Act 1996 (Tas) (s6(e)) provides that the services for persons
with mental il nesses are equitable, comprehensive, co-ordinated, accessible
and free from stigma; and in particular ensures that the standards of care
and treatment for those persons are at least equal to the standards of care
and treatment for physical illnesses and disabilities.
The Mental Health Act 2000 (Qld) (s 8(d)) aims to achieve maximum potential
and self-reliance for mental y ill patients. It provides that, to the greatest
extent practicable, a person is to be helped to achieve maximum physical,
social, psychological and emotional potential, quality of life and self-reliance.
96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] The WA Act provides that:
1. The Chief Psychiatrist in WA is responsible for: a. the medical care and welfare of all involuntary patients (s9(1)); and b. reporting to the Mental Health Review Board on matters concerning the medical care of welfare of involuntary patients (s10 (d)). 2. The Chief Psychiatrist may at any time: a. review any decision of a psychiatrist as to the treatment of any involuntary patient (s12(1)(a)); and b. vary or rescind the decision or substitute another decision for it. 3. Treatment is undefined in the WA Act. 4. Proposed treatment is to be explained to the patient before they are able to give informed consent (s97). 5. The patient is to be given time to consider whether or not to consent to treatment (s98). 6. Medical treatment for involuntary patients in an authorised hospital is to be approved by the Chief Psychiatrist (s110). It can be seen that the other Australian jurisdictions pay close attention to an
holistic treatment plan, which is underpinned by regard to the patient's
quality of life. There are no equivalent provisions in WA legislation, which
require regular physical health examinations of mental health patients. lxvi i
International jurisdictions
Scotland has done much to lead the way in law reform to improve mental
health care, most notably through the Mental Health (Care and Treatment)
(Scotland) Act 2003.lxix Since the 2003 Act, the Scottish government has
shown a strong commitment to address this issue. In "Delivering for Mental
Health", lxx the government made the commitment that:
"By 2009 we will improve the physical health of those with severe and enduring mental illness by ensuring that every such patient, where possible and appropriate has a physical health assessment at least once every 15 months." The promise was acknowledged as having been achieved to an extent in the policy and action plan launch by the government, building on the principle set out in the 2006 publication. ‘Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011'lxxi, aims to improve the mental health system in Scotland, and the wellbeing of those suffering from mental illness. These policies put a framework in place to address the issues of inequality within the health care system, and provide guidance for clinicians and service providers from mental health and primary care trusts, wider NHS, local authorities and voluntary sector organisations, who care for people with mental 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] health problems. Within their action plan, the Scottish Government sets out the priorities within this area. Priority 6 ‘improving the quality of life of those experiencing mental health problems and mental illness' includes addressing the physical health of those suffering from a mental illness." The United Kingdom (UK) has for some time clearly recognised that inadequate physical care of patients is an important issue to address to obtain equality within the health care system. UK Policies include a commissioning framework published by the Department of Health in 1996. This publication provided guidance about addressing the physical needs of people suffering from mental illness, and used examples of current practice. On the subject of physical screening the department states: "Patients ought to be offered annual reviews that include: demographic details, patient history and family history information; current medication and medication history for all health problems, plus any side effects or contraindications; basic health checks including blood pressure, pulse, body mass index (weight and height); blood tests and urine analysis; lifestyle assessments should be completed to include a review of diet, physical activity."lxxi Health care proposals were implemented in a selection of English primary care trusts in the hope that based on their success, it was stated that this program might be extended out to the wider community. Other important guidelines focusing on this issue have been published by organisations such as the Royal Col ege of Psychiatrists and the National Institute for Clinical Excellence in the UK. These focus on physical health monitoring within the field of psychiatry. In the United States, the National Alliance on Mental Illness (NAMI) assessed the USA's mental health services by looking at each State individual y (NAMI Report).lxxi i In the first category of their report ‘Health promotion and measurement' the performance by most states was extremely low. States are graded from A to F. F means a fail, and 70% of States scored D or F in 2009. Commentary suggested that because people living with mental illness die prematurely, this should compel USA state mental health and al ied agencies to take concrete steps:lxxiv  to prevent the negative side effect of medication;  to promote healthier lifestyles, address high rates of smoking in the 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected]  fully integrate mental and physical health care services. It is worth noting that the NAMI Report drew attention to 11 States, which were addressing these issues through piloting strategies, including posting nurses at community mental health centres, linking their systems with physical health providers, offering smoking cessation programs, and screening individuals for emerging diabetes concerns. Chief Psychiatrist's responsibilities
It is important to note a significant legislative and policy issue in Western
Australia. The WA Act adopts a narrow view of the Chief Psychiatrist's
responsibilities: that being authority for ‘psychiatric care'. The Chief
Psychiatrist (CP) has no authority over ‘mental health services'lxxv, which
include places like authorised hospital, declared places (none built),
residential facilities, community mental health services or licensed hostelslxxvi.
The issue was highlighted in the Holman Reportlxxvii. The Report found that
changes need to be made to authorise the Chief Psychiatrist to set standards
for the psychiatric care of mental health patients, and to monitor and take
action to ensure adherence to standards for al patients using mental health
services. This change would complement the existing responsibility that the
Chief Psychiatrist has for the medical care and welfare of al involuntary
patients: s 9(1); and the standard of psychiatric care throughout WA: s 9(2).
While it is our opinion that the Chief Psychiatrist or similar body should be
responsible for setting standards, it is our opinion that the monitoring and
taking action when performance fal s below the standard should be done by
a body independent of the Chief Psychiatrist and government. An
independent body should report directly to parliament in a report not less
than annually and that report should be required to be tabled within 14 days
of its receipt. Furthermore, there must be consequences for breaches of the
standards of care. Suitable remedies proportionate to any breach of the
standard of care must be available to the independent body, Courts and
State Administrative Tribunal.
Significant policy considerations

There are significant policy considerations regarding the statutory powers
given to the Chief Psychiatrist. The Office of Chief Psychiatrist has no authority
over Area Health Services, including
a. the lack of power of the Chief Psychiatrist to direct that a reasonable standard of care be observed by an Area Health Services; and 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] b. despite the Chief Psychiatrist being authorised to receive complaints, the office does not have the power to direct in responding to those complaints. The power to direct resides with individual health services. The clear and demonstrated failure of the system to respond adequately to the physical health needs of mental y il patients must be taken into account when deciding the role and powers of the Office of the Chief Psychiatrist, and others, under the new mental health legislation presently being considered by the WA government. Mental Health Act 1996 (WA)
The provision of physical health care and the removal of barriers to accessing physical health treatment are of fundamental importance for people suffering from a mental illness. This is reflected in the:  Convention on the Rights of Persons with Disabilities and the Disability Discrimination Act; and  Mental Health Act 1996 (WA) (WA Act). It is also noted that the Chief Psychiatrist has the power to delegate his powers: s16 WA Act. The Chief Psychiatrist has the power to consent to medical treatment of involuntary patients and mental y impaired accused: s110 WA Act; only if the patient is not capable of providing consent. The Chief Psychiatrist has delegated this power to certain psychiatrists: Operation Directive 8 March 2010. Section 5 of the WA Act provides: 5. Objects of the Act
(a) to ensure that persons having a mental il ness receive the best care and
treatment with the least restriction of their freedom and the least interference with their rights and dignity; (b) to ensure the proper protection of patients as well as the public Section 5 arguably recognises the need and importance for the provision of a holistic health care treatment program for people being treated for a serious mental unless under the Act. Section 5 requires that the rights and dignity of mental y ill patients are protected by every person and body who fal s within the definition of section 6 of the Act. In the case of Royal Women's Hospital v Medical Practitioners Board, it was held that: 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] "the provisions of international treaties are relevant to statutory interpretation. In the absence of a clear statement of intention to the contrary, a statute (Commonwealth or State) should be interpreted and applied, as far as it language permits, so that it conforms with Australia's obligations under a relevant treaty."lxxvii Thus, "best care and treatment" in s5 (a) arguably means that treatment must meet the needs as wel as address the medical problems, both physical and mental, faced by patients, the subject of the WA Act in an holistic and integrated treatment plan and that this would best serve the needs of the mental y ill patients, while ensuring that their treatment is at least equivalent to that received by other members of society. This can only be effectively promoted through a monthly physical check up by a medical practitioner external to the mental health service. Section 6 of the WA Act imposes a duty of care on the Minister, departmental officers and bodies administering the medical care and treatment provided for the mental y ill patients. Section 7(a) of the WA Act imposes, on the Minister, a duty to promote the development and co-ordination of services for the care and treatment of persons who have mental illnesses and in doing so, ensure that the objects of the Act are achieved so far as it is relevant to the performance of his or her functions under this Act. It includes the fol owing: 7. Functions of the Minister
It is a function of the Minister —
(a) to promote the development and co-ordination of services for the care and treatment of persons who have mental il nesses; (b) to promote the integration of, and co-operation between, health and welfare services at State, regional, and local levels for step… The WA Act also imposes a duty on the Chief Psychiatrist. While the duty mainly focuses on the mental health aspects of the involuntary patient, s9 (1) provides the fol owing: 9. Responsibilities of Chief Psychiatrist for psychiatric care
(1) The Chief Psychiatrist has responsibility for the medical care and
welfare of al
involuntary patients.
96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Arguably, the Minister and the Chief Psychiatrist have a duty to provide an
holistic and integrated health care to each involuntary patient. The statutory
status quo clearly has not delivered given the present plight of involuntary
patients' physical health needs in Western Australia. We note that the Chief
Psychiatrist has the power to delegate these responsibilities. It is arguable that
the Chief Psychiatrist should not be authorised to delegate this responsibility,
because it is not working.
Recommendations
From the illustrative case studies in this submission, it is apparent that more needs to be done to ensure that the quality of medical treatment is provided equal y to al members of the community, including those with a mental il ness. The fact that a person is mentally il should not affect the quality or accessibility of their physical medical treatment. The lack of continued care, which addresses both the physical and mental health needs, can have severe repercussions such as death, as was the case of Ms V, who died from constipation. This was a death, which could have been prevented if she had been examined by an independent GP. While the objectives of the Mental Health Act 1996 (WA) point in the right direction, certain aspects of the Act are vague, silent and/or insufficient when it comes to the responding to the physical health needs of involuntary patients. We propose the fol owing urgent amendments of the Mental Health Act 1996 (WA) and recommend their inclusion in the new Mental Health Bill: 22. "Best care and treatment" must be defined to include accessible provision of both physical, dental and mental health care treatment to al involuntary patients and voluntary patients admitted to or present in an authorised place and declared place, and all patients on Community Treatment Orders. 23. A person, because of his status of involuntary patient or patient in an authorised hospital should not be at a disadvantage when it comes to accessing physical health care treatment. The need for an integrated and holistic treatment plan, which will ensure the continued care of voluntary and involuntary patients, can be achieved as fol ows and should be included in the Bill: 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] 24. A General Physical Examination (GPE) must be conducted for all involuntary patients and all voluntary patients admitted or in authorised hospitals by an independent general practitioner as fol ows: (a) An initial GPE must be conducted on admission, which would enable examination to be meaningful y conducted, within 24 hours but not later than within one week of admission. (b) The GPE conducted regularly as prescribed or at least monthly for involuntary patients detained in hospital. 25. The greater frequency of the GPE must be provided in response to needs arising from factors including: (f) The severity of the mental il ness experienced by the involuntary patient; (g) The variety and quantity of psychiatric medication that has been prescribed to the patient by his or her psychiatrist; (h) The patient's medical history (diabetes etc.) and patient's physical health care needs; (i) The likely side effects of the patient's medications; (j) Signs and symptoms exhibited by the patient. 26. The GPE wil also include an initial and annual dental examination and follow up dental treatment as needed. The purpose of 4(a) and 4(b) above is to ensure that patients receiving medications directed at treating their mental illness have the opportunity and access to a general practitioner because of the impact of the side effects such medication can have on physical health, which can be highly detrimental if not addressed promptly. Recommendation 5 recognises the importance of dental health as a part of our overal health and wellbeing. 27. Both the Minister and Chief psychiatrist must ensure : d. Physical il ness, including side effects from treatment, of involuntary and voluntary patients in authorised hospitals are met through a general physical examination and treatment by an independent general 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] practitioner, or as referred by the GP, and not by the treating psychiatrist or other members of the treating team. e. The Minister must ensure that involuntary patients and voluntary patients in authorised hospitals can easily and equally access timely physical health care treatment. f. In the event that an involuntary patient is a child or a young adult, in addition, their developmental needs must be taken into consideration when deciding on treatment for their mental and /or physical il ness. Part 7 places a statutory duty of care upon the Minister and the Chief Psychiatrist to ensure that involuntary patients can easily access physical health care and specialist care without disadvantage. Mental Health Bill 2011 (WA)
1. The objects of the Bill should be amended to include specific reference to meeting the physical and dental health needs of people, the subject of the Bill. 2. The Charter, which is included in Schedule 1 of the Bill, should be moved to be included in the Bill after the Objects to increase its strength and recognition and credibility. It should also be measured against al the relevant Conventions to which Australia is a signatory and amended accordingly (see Annexure Two for a start on this analysis). 3. Al provisions in the Bil where regard is to be had to the Charter must be couched in mandatory terms, not discretionary terms, because the terms of the Charter itself are not binding. The Charter wil be toothless otherwise. Part 3, clause 8 of the Bill must include mandatory reporting to the Chief Psychiatrist who in turn must make report in the Annual Report, when the Charter has been departed from including the reasons and decision by the CP whether or not the departure was justified. 4. The Charter has included a provision relating to physical health needs of people, the subject of the Bill. The inclusion of the word "other" is curious and inexplicable and should be removed from clause 8 of the Charter. Furthermore, the words "and dental" should be inserted after the word physical in clause 8 of the Charter. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] 5. Clause 59 of the Bill provides that the treating psychiatrist must report regularly to Chief Psychiatrist. While cl 59(1)(a) provides that the treating psychiatrist must report to the Chief Psychiatrist about the patient's mental and physical condition, it does not and should include a medical review undertaken by an independent GP at least once a month and an annual review by a specialist physician and dentist. The opinion of an independent GP should also be taken into account when the treating psychiatrist reports to the Chief Psychiatrist. 6. Clause 106 of the Bill provides that the involuntary community patient must be examined by the supervising psychiatrist, a medical practitioner or a mental health practitioner. While cl 106(2) ensures that an involuntary patient will be examined by a supervising psychiatrist, a mental health practitioner or a medical practitioner, it does not make mandatory a monthly check-up carried out by an independent general practitioner , or an annual examination by a physician and a dentist. Such a check-up should be mandatory and this should be expressly stated in the Bill. 7. Clause 106 should make mandatory a monthly physical check-up provided by a GP, and an annual check-up by a specialist physician and dentist, as should the terms of a CTO. The reports from these practitioners should then be provided to the treating psychiatrist. The treating psychiatrist, general practitioner and dentist should work closely to ensure that a patient's mental and physical health needs are addressed. In the course of this process, the patient should also be referred to other medical professionals such as dentists, and specialties as needed and these referrals should be attended to in a timely manner, and where a referral has been made a copy should be provided to the MHT. 8. Clause 107 of the Bil provides that the supervising psychiatrist may request a practitioner to examine an involuntary community patient. While this clause appears to be for the purpose of whether or not involuntary status should continue, or could be expanded to include examinations for physical and dental health as necessary, and not less often than certain prescribed periods. 9. Clause 148 of the Bill provides that the treatment, care and support provided to a patient must be governed as far as practicable by a treatment, support and discharge plan. Cl 148 aims to ensure that a 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] patient is provided with a clear treatment plan to which he or she will adhere. Clause 148 must clearly prescribe that the plan is to be overseen by both a treating practitioner (as stated in cl 122) and an independent GP. An independent GP would monitor the progress made in terms of a patient's physical health, while also keeping track of any harmful physical and/or dental side effects experienced by the patient in the course of receiving his or her treatment. 10. By clearly defining the roles of the treating psychiatrist and general practitioner in the treatment, support and discharge plan the approach wil be more holistic, there will be greater accountability and there will be an increased chance of a sustained recovery. This personalisation of the care plan is consistent with the Minister's objectives for people who are subject to mental health legislation. Involuntary patient status should not cause a person to be at a greater health disadvantage than if they remained a voluntary patient. Our proposed model would mean that involuntary patients would benefit from an holistic treatment plan. 11. Clause 202 of the Bil requires a physical examination of a patient admitted to an authorised hospital, which is defined at clause 423 to include various places. In our opinion clause 202 wil not remedy the problem presently faced by involuntary patients. The Bill simply gives expression to a standard of care that presently exists for admission to any hospital (although unstated in the current MH Act) for patients admitted involuntarily to authorised places, that is the accepted standard of care would require a physical examination to take place on admission. In the Centre's experience as witnessed by medical records, this obligation is not always observed and we do not understand how the statement of a requirement that already exists will resolve the physical and dental health ill health currently faced by involuntary patients, especial y inpatients. There is no requirement in the Bill to obtain external independent monitoring of the physical and dental health of patients the subject of the Bill. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Furthermore, the Bill makes no consequences for failure to observe the mandatory requirements of clause 202, and it should, otherwise there will be little change. In our opinion, the Bill does not have the propensity to significantly improve the response to the physical and dental health needs of patients, the subject of the Bill It is critical for the improvement of the outcomes for involuntary patients that they receive regular physical examinations conducted by a medical practitioner independent of the mental health services. While the Mental Health Bill 2011 (the Bil ) attempts to address some of the issues raised in this article, more must be done to ensure that mental y ill involuntary patients are provided with holistic health care treatment. The Bil does not include a mandatory regular physical check up by an independent medical practitioner and it should. By incorporating independent GPs into the involuntary patient procedures, both a patient's mental and physical health problems will be addressed. This also wil improve accountability. Furthermore, the harmful side effects which may arise as a result of psychiatric treatment can be more effectively treated, the chances of it being overlooked will be reduced and mistaken aetiology and diagnoses are likely to be remedied. Furthermore, for example some patients are not taken out of their secure environments every day to breathe and feel fresh air and sunlight, or encouraged sufficiently to exercise. There should be provisions to require this. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] The issue of consent to medical screening and examination of voluntary and
involuntary patients, who are adults or minors, is not addressed in this paper.
The issue of informed consent requires careful examination and an ethical
balancing act between the best interests and the rights of a patient, which
requires further examination.
Clause 202 (3) of the Bil requires careful consideration and arguably should
include consent to be required from someone outside of the mental health
service who has the best interests of the patient at heart, or is required to
have as its priority the best interests of the patient. Furthermore, consent for
children and adolescents should be even more guarded and the child or
adolescent must be legal y advised and represented, as indeed should be
the requirement for any child or adolescent who becomes subject to mental
health care and protection legislation.
Conclusionlxxix

What is in place in the existing Mental Health Act to protect the physical health of involuntary patients and voluntary patients in authorised hospitals does not appear to reach an appropriate statutory protection of their interests. Whether or not it is simply a resourcing issue, law reform is essential to prescribe a minimum standard to ensure that the delivery of holistic health care to patients detained or residing in authorised hospitals (and any other places where involuntary patients can be detained) is improved. The Bill must introduce and require regular independent physical health medical and dental examinations of people who are detained and/or treated involuntarily for a mental illness. This is essential to protect their 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] fundamental human rights and to ensure that they are receiving appropriate holistic attention to their health. Physical ill health signs and symptoms exhibited by mental health patients must be addressed on an equal footing with their mental illness. In any event, in this respect the Bil simply gives expression to a standard of care that presently exists unstated in the MH Act for patients admitted involuntarily to authorised places that is for a physical examination to take place on admission. In our experience, this obligation is not always observed Independent health care services must be integrated with mental health services to al ow for the provision of accessible health care to people with mental illness. A single physical examination upon admittance to an authorised hospital, while critical y important is not sufficient. Patients involuntarily detained and/or treated for a mental illness must receive an examination by an independent general practitioner from outside the service (possibly on a monthly basis) to ensure that their physical health is maintained or improved and that any health problems are identified and treated in a timely manner. Al involuntary and voluntary patients in authorised hospitals must receive an initial annual examination by a specialist physician independent of the hospital. There must be a statutory requirement for prompt compliance with expert referrals from the GP responsible for the patient. This reform will not only benefit the physical health of involuntary patients in authorised hospitals, it wil also promote the habit of regularly visiting a GP, which will assist patients in maintaining and/or developing social skills and give them improved chances of living healthier lives on release into the community. An established relationship with an independent GP may reduce the need for a full history to be taken every time an involuntary patient requires medical treatment particularly when there may be circumstances where such a history cannot be taken. This in turn will make treating mental health patients' illnesses easier, quicker and more efficient, which is especially important when the mental illness has unpredictable serious relapses. Surely, the bureaucratic, funding and administrative impediments to providing such a basic level of service to reduce the disparity in the quality of health care service between the general population and involuntary patients detained in an authorised hospital in Western Australia can be overcome? 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] Furthermore, these patients should be provided with the opportunity to live a
healthy lifestyle and this sometimes just involves the basic liberty to see
sunshine, get some fresh air and the opportunity to get some exercise. As
basic as it may seem, it may go a long way in improving both the physical
and mental wellbeing of the patients.
Our proposed model can be considered to be a bottoms-up approach to
needs assessment. This is fundamental to sensibly estimate need and
produce estimates to inform planning of specialist primary care, and public
health services for treatment, rehabilitation, and prevention in a balanced
mental health care system.lxxx
If none of the outcomes expressed in this paper raise human rights concerns
or distress about the welfare of these patients in the reader, then there is an
economic argument in favour of our proposals. By improving the outcomes
for involuntary patients by responding adequately to their physical and
dental health needs, their chances of recovery are enhanced, which in turn
will reduce their demands on the system in the long run and make the limited
available resources go further.
We note for the sake of completeness that al mental y impaired accused
who are the subject of custody orderslxxxi should receive the same care and
protection outlined in the paper, wherever they are detained.


i Holman Report.
Holman CDJ. The Way Forward. Recommendations of the Review of the Mental Health Act 1996.Perth: Government of Western Australia, 2003. ii It is noted here that many patients of authorised hospitals are "voluntary" patients and any recommendations in this paper should apply to all patients in authorised hospitals regardless of their status. iii Report on the Review of the Mental Health Act 1996 30 August 2004/1. The Way Forward for Mental Health Legislation in Western Australia. Report on the review of the mental health act 1996. The Government Response to the Review's Recommendations. iv Australian Health Ministers 2003, National Mental Health Plan 2003-08, Australian Government, v Australian Bureau of Statistics: National Survey of Mental Health and Wellbeing 2007. vi 4824.0.55.001 Mental Health in Australia : A Snapshot, 2004-05 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] on the 15th of August 2011. vi Coghlan R, Lawrence D, Holman CDJ, Jablensky AV (2001) Duty to Care: Physical illness in people with mental illness. Perth The University of Western Australia. vi i Lawrence D, Holman D, Jablensky A. (2001).Duty to Care: Preventable Physical Illness in People with Mental Illness. Perth: The University of Western Australia. ix International Journal of Nursing Studies 44 (2007) 457–466 Serious mental illness and physical health problems: A discussion paper Debbie Robson, Richard Gray. x International Journal of Nursing Studies 44 (2007) 457–466 Serious mental illness and physical health problems: A discussion paper Debbie Robson, Richard Gray p463. xi Friedlander, A.H., Marder, S.R., 2002. The psychopathology, medical management and dental implications of schizophrenia. Journal of American Dental Association 133, 603–610. xii Epilepsy foundation of Victoria, Australia,. xii National Oral Health Plan 2004-2013. Prepared by the National Health Advisory Committee on Oral Health. A committee established by the Australian Health Ministers' Conference. xivNational Dental Update August 2004: Australia's National Oral Health Plan 2004-2010 Part one. xv Oral health preventive protocol for mentally disabled subjects – A review by Ajay Bhambal, Manish Jain Sudhanshu Saxena and Sonal Kothari Journal of Advanced Dental Research Vol II: Issue Me: xvi Dr Peer Sulaiman (B.D.S) Tamil Nadu Dr.MGR University, Tamil Nadu, Chennai India. 11th August 2011. xvi Dr Sulaiman Mohammed (M.D.S) , Oro Maxillofacial Surgeon King Khalid Hospital , Ministry of Health Hail, Kingdom of Saudi Arabia . 11th August 2011. xvi i Ibid. xix Dr Peer Sulaiman (B.D.S) Tamil Nadu Dr.MGR University, Tamil Nadu, Chennai India 11th August 2011. xx Castle D, Lambert T, Melbourne S, Cox A, Boardman G, Fairest K, et al. A clinical monitoring system for clozapine Australasian Psychiatry 2006; 14(2):156-68. xxi Physical Health for People living with a Mental Illness, North Coast Area Health Service xxii Summary of Research Outputs Project WA Data Linkage Unit (1995 to 2003) accessed on 20 October 2011. xxii Coghlan R, Lawrence D, Holman CDJ, Jablensky AV (2001) Duty to Care: Physical illness in people with mental illness. Perth The University of Western Australia See also the work of Susanne Stanley, psychiatry and neurosciences researcher at the University of Western Australia. xxiv Mental Health Council of Australia submission on Australia's Draft Initial Report under the Convention on the Rights of Persons with Disabilities August 2010 Article 25: Health xxvi We include dental health when we refer to physical health in this paper. 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] xxvi Anna Lawson, "The United Nations Convention on the Rights of Persons with Disabilities; New Era or False Dawn?" Syracuse J Int Law Commer 34 no2 Spr 2007 xxvi i ‘Inequalities in healthcare provision for people with severe mental illness' David Lawrence, Stephen Kisley J Psychopharmacol 2010 November; 24(11_supplement): 61–68 xxx Sandra Boulter, Principal Solicitor and General Manager of the Mental Health Law Centre (WA) Inc. xxxii Principal Solicitor/General Manager, Sandra Boulter xxxiv Leucht S, Burkhard T, Henderson J, Maj M, Sartorius N. (2007) Physical Illness and Schizophrenia: A Review of the Evidence Cambridge: Cambridge University Press xxxv - 7. Jeste DV, Gladsjo JA, Lindamer LA, Lacro JP. Medical comorbidity in schizophrenia Schizophrenia Bull 1996; 22:413–427 xxxvi Coghlan R, Lawrence D, Holman CDJ, Jablensky AV (2001) Duty to Care: Physical illness in people with mental illness. Perth The University of Western Australia xxxvi i Record of Investigation into Death Ref 12/09 Western Australia xxxix xxxix New Zealand Coroner's Report into the death of Mr Scott Miles Chapman, Nelson Coroner's Court Ref 20/2011, who was a 28 year old man with schizophrenia and diabetes; about Tony Rosimini who died while on an indefinite CTO Rosimini [2011] NZCORC96 (25 July 2011). (accessed on 12th January 2012) xli Furthermore, specialist mental health services should be gender sensitive and responsive to the needs of gay, lesbian , bisexual, transgender and intersex (GLBTI) clients and people from culturally and linguistically diverse backgrounds. This is reflected in the Queensland legislation: S8E of the Mental Health Law Act 2000 (Qld) provides that a person's age-related, gender-related, religious, cultural, language, communication and other special needs must be taken into account. xli Access to Health Services by People with Mental Illness , mental Health Council of Australia xli i Australian research Alliance for Children and Youth 2008, The Wellbeing of Australians: report card p.4. xliv Department of Health, Mental Health Division (England) 2010, New Horizons: Confident communities brighter futures a framework for developing wellbeing, England 26. xlv Report of the Inquiry into the mental health and wellbeing of children and 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] young people in Western Australia April 2011 xlvi Convention on the Rights of the Child, Article 3.1 [website], viewed 2 at March 2011, of the Rights of Persons and Disabilities, Article 7, viewed 2 March 2011, http://www.un.org/disabilities/convention/conventionfull.shtml. xlvi Productivity Commission 2010, Report on Government Services 2010 (2007-08 data) Canberra, p.15.57. xlvi i Potter, D 2010, "Mental Health Issues in the Children's Court Jurisdiction', Brief, Journal of the Law Society WA, vol 37, no.9, p.16 xlix Submission No.21 from the Office of the Inspector of Custodial Services p.2 l Mental Health Commission, 2010, WA Mental Health Towards 2020: Consultation Paper, Government of Western Australia, p.15. li Submission No.55 from The Children's Guardian (NSW); submission No.27 from The Royal Australian % New Zealand College of Psychiatrists WA Branch li Royal Australian and New Zealand College of Psychiatrists 2008, The mental health care needs of children in out-of-home care: A report from the expert working committee of the Faculty and child and Adolescent Psychiatry , pp.19-20 [website], viewed 17 February 2011, li i Mental Health Act 2009 (SA) liv Australian Research Alliance for Children and Youth The Wellbeing of Young Australians: Technical Report, ARACY, 2008, p. 1 lv Mental Health Chief Psychiatrist's Guideline: Physical Examination, the Annual Examination and Attention to Clients' General Medical Health Needs. Report by the Office of the Chief Psychiatrist. August 2002. lvi Submission to the State Mental Health Policy and Strategic Plan 2010–2020 for Western Australia Commissioner for children and young people Western Australia lvi Report of the Inquiry into the mental health and wellbeing of children and young people in Western Australia April 2011 lvi i Ibid. lix Zubrick S.et al. Western Australian Child Health Survey: Developing health and wellbeing in the nineties. Perth: Australian Bureau of Statistics and the Institute of Child Health Research; 1998 lx Sawyer M. et al The Mental Health of Young People in Australia Canberra: Commonwealth Department of Health and Aged Care, 2000. lxi Report of an Announced Inspection of Casuarina Prison Report No. 68 (2010) lxii Report of an Announced Inspection of Boronia Pre-release Centre for Women Report No.62 (2009) lxii Report No. 60 (2009) lxiv United Nations Convention on the Rights of Persons with Disabilities lxvArticle 25 United Nations Convention on the Rights of Persons with Disabilities lxvi Mental Health Act 2009 (SA), part 2, s 7 (1)(d) lxvi Mental Health Act 1986 (Vic), part 5, division 5, s 87 lxvi i The MHLC has submitted that these provisions are included in the objects of the Act: see MHLC submission Objects and Principles in the Act. lxix Mental Health (Care and Treatment) (Scotland) Act 2003 96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected] lxx ‘Delivering for mental health' the mental health delivery plan for Scotland, sets out targets and commitments for the development of mental health services in Scotland. lxxi Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011' ISBN 978 0 7559 5962 4 lxxii Choosing Health: Supporting the physical needs of people with severe mental illness commissioning framework, Department of Health ,Published 17 August 2006
lxxv Mental Health Act 1996 (WA), part 2, division 2, s 9 lxxvi Holman Report at 2.2 lxxvi Holman Report at 2.1 lxxvi i Royal Women's Hospital v Medical Practitioners Board (2006) 15 VR 22 [75] lxxix The issue of consent to a medical examination and treatment for a physical illness, is not addressed in this paper. It is a contentious issue that must be responded to. In Western Australia, an application can be made for a guardian to be appointed under the Guardianship and Administration Act 1990. The State Administrative Tribunal can order that a guardian be appointed to make decisions about various things, including giving consent to medical treatment. The present Chief Psychiatrist has the power to consent to medical treatment of an involuntary patient who is not capable of giving informed consent. The Chief Psychiatrist has delegated this power to a member of psychiatrists. There appears to
be little public or independent examination of the efficacy or reasonableness of this delegated
authority.
lxxx Mental Disorder in Canada: An Epidemiological Perspective By John Cairney, David L. Streiner,
University of Toronto Press Incorporated 2010.
lxxxi Indefinite detention authorised and monitored under the Criminal Law (Mentally Impaired Accused)
Act 1996 (WA)


96-98 Parry Street, Perth WA 6000 - PO Box 8466 Perth Business Centre WA 6849 Phone: (08) 9328 8266 Fax: (08) 9328 8577 Freecall from landline: 1800 620 285 www.mhlcwa.org.au Email: [email protected]

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