It is only eight short years since I was appointed to lead the national peak organisation in Australia, Suicide Prevention Australia. Little did I know then that it would lead me to be part of the global movement to deliver better quality and more accessible care to those who experience mental health crisis and are vulnerable to suicide. Today, having established the Zero Suicide Institute of Australia, I’m focused on advocating for a more seamless pathway of care that is responsive to individual needs. And never has there been a greater need, nor opportunity, to transform our mental health services to support those impacted, not once but many times over, by circumstances beyond their control.
In January this year, the world watched Australia as homes burned to the ground, businesses were lost, and wildlife struggled to survive the terrible fires that engulfed the country. On the other side of the world in the United Kingdom, houses were awash with floodwaters, and livelihoods were lost. These very visible events clearly show the impact that climate change is having on the lives of people across the globe. What is not clear is the longer-term impact that these tragedies have on the lives of individuals, families, and whole communities. Now we are dealing with a global pandemic: COVID-19. A virus we don’t understand that might attack communities and nations over and over.
When the flames die down, when social distancing is retracted, when the virus and water recede, and the visible signs are gone, it’s all too easy to forget the impact on people—both their physical and mental health needs. Good crisis care should be available for everyone, everywhere, and every time. This, however, raises the question of what is optimal care for those experiencing a mental health crisis? It was this question that a gathering of mental health and suicide prevention leaders from 12 countries grappled with during the International Initiative for Mental Health Leadership (IIMHL) and Crisis Now Summit meetings held jointly in Washington DC in September 2019. #CrisisTalk sat down with program committee members Dr. Caroline Dollery and Dr. Phil Moore, from the U.K., to discuss the meeting and its outcomes.
Dr. Dollery and Dr. Moore agreed that the meetings were an opportunity for country leaders to come together to share knowledge and design a better model of mental health crisis care. One that ensures people with mental ill-health crises receive a response to treatment and recovery that is equitable with the care delivered to patients diagnosed with cancer and other chronic medical emergencies. There was universal agreement from the meeting that influencing health systems in a way that provides parity with a medical emergency was a key requirement. Common to all country delegates was that too many people are cared for in inappropriate places, essentially being boarded while waiting for beds. Emergency Departments (EDs) are not the appropriate place for someone experiencing a mental ill-health crisis. This is true now more than ever as EDs and hospitals are overwhelmed with COVID-19 and are a source of infection.
An International Declaration to Overcome Disparities in Healthcare Systems
It was also important to understand what support might be needed by other nations where the health system is not so stable. What could be done to support under-resourced countries? And what could we learn about what works well in those countries despite the disparities that exist between different health systems? Dr. Moore felt strongly that there is a need to work at the national level to influence policy and locally to influence practice. From a policy perspective, an important outcome from the meeting will be the development of an international declaration on crisis care. This document will provide support for those at the meeting to influence the political, social, and economic agendas of their governments.
In practice, there is a need for innovation in delivering quality care outside an institutional setting while also giving people confidence that there is a secure safety net in place. Dr. Dollery agreed, adding that it was important to harness wider community networks to bring pressure to bear on politicians to create the political will needed to invest in the delivery of care in communities where people live, work, and play. Care pathways need to reduce social isolation and offer crisis support focused on recovery.
When people do enter the healthcare system, they have every right to expect and receive consistent good quality care. Several key issues were identified at the meeting that are critical for quality crisis care.
- We need an agreed national policy that ensures services are integrated to effectively support one another to build a robust and responsive system.
- We need to address diversity.
- We need opportunities to understand best practices, share ideas, and give support to one another.
Change Must Be Data-Driven
According to Dr. Dollery, none of the elements needed for an effective system can be developed without data. Without timely, accurate, and quality data we cannot exert the right influence. We cannot understand diversity. We cannot demonstrate inequities. Nor can we measure if an integrated and supportive system is delivering improved outcomes.
We also know that data is essential to building the evidence-based approaches that deliver improvements. This has been demonstrated ad nauseam for medical emergencies. Why is it any different for mental health emergencies? Effort needs to be put into winning hearts and minds of non-mental health professionals so that doctors recognise the inter-relationship of mental and physical health and support a holistic approach. One avenue to address this irrespective of the sophistication of the health system is to ensure it is included in undergraduate training for doctors and nurses.
Everyone agreed that investment needs to be made in prevention so that we can avert crisis situations. Dr. Dollery explained that in the U.K., the cost of not treating mental ill-health is 10 times the cost of treating it, because of the extent to which the impact reaches out into the wider community. So, until prevention is the norm, for a person experiencing a mental ill-health crisis, there must be options available to them to help manage the situation.
This led both of the doctors to comment on the prominence of lived experience across all discussions over the two days, especially when personal experiences of hospital emergency departments were presented. In some countries, there is increasing interest in Safe Haven Cafes as an alternative to emergency department presentations. These are good for some people, but Dr. Moore urged caution—this is not the sole solution. It needs to be part of a vital system that offers clinical care fit to need.
A National Crisis Number
An important part of the solution is a national crisis number, which can be answered locally with a directory of local services to which people can be referred. But the real key, the critical factor, is the integration of these services with lived experience informing services at every point within the system.
Building off the phone system is the need for outreach services that go to the person. Offering support at a place of the person’s choosing. The outreach team needs to have capabilities, knowledge, and skills to give appropriate access to care. Then if this is not sufficient, the person should have access to a stabilisation centre that is purpose-built to provide comfortable, safe, and effective crisis care far removed from the high traffic intense nature of hospital emergency departments. Then, Dr. Dollery added, we need to know how to measure whether this multi-level, integrated mental health system is working.
What to Keep in Mind When Redesigning a Crisis System
Finally, we asked what is the one piece of advice you would offer to health professionals and people designing crisis systems?
For Dr. Dollery, it was to work with communities to understand why change is needed and implement a consistent, well-planned model of care. Know who you need to work with on your patch to enable this to be rolled out effectively and speedily.
For Dr. Moore, it was …. step into others’ shoes. Try to understand what it must be like to be vulnerable. he said:
“For health professionals to truly understand they need to put trust in, and place value on, the insights that come from those with lived experience. Such insights are what is needed to help us truly define a quality crisis system.”
You can read the newly released Washington DC International Declaration here.
A health promotion advocate in Australia dedicated to improving the health and well being of all people. Throughout her career, she has focused on health for the community and has expertise in communications, education, and organisational development.
Sue currently leads the Zero Suicide Institute of Australia, which aims to support the healthcare system to understand and more effectively manage those who are vulnerable to suicide and suicidal behaviour.