With the election looming and only days away, I am still concerned about the future of rural health and in particular rural mental health. Very little has been proposed about mental health, less about rural mental health, and even less about young rural people’s mental health. I think that is a big concern – the invisible problems that exist, still have very little political light shed upon them, or political will to improve the odds.

I have spent all of my nursing career caring for rural and regional people, most of them with mental health problems; teaching others how to care for them; and conducting research so that their is growing evidence about how to help people better, earlier, and more effectively. My view is that nurses are experts with health promotion, well-being, and recovery – yet we are not consulted about solutions for health problems in Australia nearly often enough.  We are not always good at speaking up when we should either – despite our focus on advocating for health and well-being…we nurses should do better, but so too should our politicians. So, I am looking at this election through a rural mental health nurse lens – and this is what I see so far:

• Labor – Government – nothing new in terms of mental health offerings. More headspace is a really nice thing for the 90 communities that are lucky enough to have them, but they should be in every community, not just the select and lucky few. Virtual clinics – no substitute for on the ground face to face services for young rural people – just not enough to make a real grass roots difference. Mental health Nurse Incentive Program remains frozen with no plans to fix. (http://www.alp.org.au/betterhealth)
• Coalition – opposition – no better! 10 more headspaces (total 100) for the country and e- mental health for young people, a bit a R&D – but in reality very little substantial improvement which translates to very little extra for rural young  people. No news about Mental Health Nurse Incentive program at all  – a concern because they are silent on this important matter. (http://www.liberal.org.au/latest-news/2013/08/30/coalitions-policy-improve-mental-health)
• Greens are a little more hopeful – while they too would seek to expand they headspace model – they are at least open to other models of care as well. The Greens have a rural mental health policy and seem to have listened to rural people about their issues, and are prepared to work with rural people to improve rural mental health. Importantly, and with a real point of difference, the Greens will expand the Mental Health Nurse Incentive Program. (http://greens.org.au/ruralMH).
• My local independent candidate – @Rob_Taber is very concerned about mental health of rural young people – and has a community service background helping out young rural people with mental health and behavioural/ social/ family problems.  He has some real life experiences it seems, and therefore a platform of some experience to work. (www.robtaber.com.au)

A major oversight is the role of nurses in mental health policy and planning for the Australian people. Nurses have a great deal of capacity to mitigate mental health problems in our society. The Mental Health Nurse Incentive Program has demonstrated just how effective nurses can be in primary care settings, where they have provided care to lots of people, helped people to remain well and not to need hospitalisation at a rate not seen before – in fact, according to a commissioned evaluation of the the MHNIP it is clear that they were almost cost neutral in many cases. That is, to see people in primary care settings offset the cost of hospital stays, and where hospital stays were needed the stays were shorter, representing very good value for money, and better health and well-being for people with persistent and severe mental health problems (not terms I like – but the ones the medicare framework uses to describe the funding arrangement). What’s more the MHNIP did this for 1000’s of people on a budget of an oily rag (and unfairly so). The program proves nurses are effective in reducing the burden of mental illness in  Australia – PROVES! But, the Government decided to freeze it – when it was working, rather than to budget more effectively for it, preferring to fund the the magazine glossy approaches to mental health care (eg a few more sparkly headspace centres – not that there is anything fundamentally wrong with headspace, just as a I said before too few). MHNIP works extremely well – it needs to be funded and better funded to reflect the education and experience of the Mental Health Nurses have as a minimum entry point to work in the program (ie at least 5 years University education and about he same as a minimum in clinical practice experience). These highly qualified mental health experts should expect remuneration at a level that is commensurate with their training and expertise (which is more than it currently is = about the level of a early career Registered Nurse). The report goes into more important detail – and can be downloaded here http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-e-evalnurs

That aside, this is a snap shot of where things are at:

• 2,273 people died by suicide in 2011 (latest ABS stats) making it the 15th most common cause of death in Australia – although it is probably higher than that because…
• A total of 9,123 people died (2011) of causes that could have been suicide but it is not clear in all cases (eg motor vehicle accidents…)
• Over three-quarters (76.0%) of people who died by suicide were male, making suicide the 10th leading cause of death for males.
• Deaths due to suicide occurred at a rate of 9.9 per 100,000 population in 2011.
• 65% of all mental illness starts during the ages 12-25 years of age –intervention needed during this crucial period.
• People in rural communities self-report that they experience mental illness and behavioural problems at a rate of 16 per cent higher than their urban counterparts (Australian Bureau of Statistics(ABS), 2011).
• Suicide rates among rural males, and especially young men aged 15–29 years, have been increasing over the past 20 years (Department of Health, 2013) and at rates twice as high as young men who live in urban communities (ABS, 2011).
•  Rural older men aged 85 years and over have been reported as having the highest rate of death by suicide, at 40 deaths per 100 000 men, and this is thought to be influenced by increased financial insecurity and agricultural stresses sometimes brought about by the experience of environmental events such as floods, droughts and bush fires (ABS, 2011)
• Loneliness and difficulty accessing mental health care are factors related to suicide (ABS, 2011)
• The further people live away from an urban centre, the less they are likely to have access to general practitioner services, and the less likely they are to utilise national Medicare initiatives, such as the Better Access initiative & Mental Health Nurse Incentive Scheme (Department of Health and Ageing, 2013
• Disparity of young rural people duration  of untreated mental illness 2yrs- 10 yrs (urban counterparts 6mths-2 yrs)
• 12 month prevalence of mental illness is more than one in four young people (28%)
• Suicide is leading cause of death for people 16-25 years of age – about one in every four deaths (comparison – higher rate than deaths by car accident in Australia)
• On average every year 12 class in Australia will have one student who has attempted suicide (Mendoza, J., Bresnan, A., Rosenberg, S., Elson, A., Gilbert, Y., Long, P., et al. (2013). Obsessive Hope Disorder: Reflections on 30 years of mental health reform in Australia and visions for the future. Summary Report. Caloundra, QLD: ConNetica.).
• 2% of young men report suicide attempt in previous 12 months
• Nearly 20% of young men report  ‘life not worth living’ (Mendoza et al 2013)
• 4 out of 10 young people binge drink regularly (39%)
• 19% young people report self harming life time prevalence
• Only one headspace in New England, NSW region – and it is new to Tamworth….

http://www.health.gov.au/mentalhealth

Solutions: My ideas for making some improvements in rural mental health…..

• Need a ‘headspace’ centre in every community. Headspace initiative is only OK if there is one in every community. The current plan is something like 90 nationwide…. Falls way short of need – and it’s not well suited to rural communities.
• Need to use rural nurses better – co locate nurses in schools, police stations, juvenile justice centre’s, and GP surgeries. An extension of the mental health nurse incentive program (MHNIP) should accommodate this (medicare funded). But, with a focus on a gateway to mental promotion, helping at the emergent phases and to promote early identification and early intervention where it is needed.

WHY… because:

• Nurses are expert at caring and listening and that is the starting point for practical mental health care. Nurses can listen, assess and refer to further appropriate help – first line resource needed. Nurses are ideal clinicians to enhance the very tricky phase of transition  informal community care to primary care transition to mental health service/care (WHO category)

• Youth mental health needs to be a priority – nationally because most mental illness starts during youth phase.
• Early Intervention needs to be a stronger focus – but even that is at a rather too late phase – mental health prevention and promotion are the key to reducing the burden of mental illness – but you don’t ever get statistics to support that – because if you prevent people from becoming unwell, than they don’t become an illness statistic and you can’t prove you have done anything worthwhile – a paradox

• Figure  above World Health Organisation (WHO) pyramid for optimal mix off mental health services (brief online document in link below).
• http://www.who.int/mental_health/policy/services/2_Optimal%20Mix%20of%20Services_Infosheet.pdf

MY VOTE COUNTS:

I live in the New England Electorate – my choice of vote is limited by the strength of the candidates in my electorate (as is the case for everyone…..). My news and interaction with others about politics is mostly gained via social media (perhaps more so than any other election). I have made an attempt to contact (via twitter) all of the candidates in my electorate to understand their views about issues on which I base my vote – one of which is rural mental health. Twitter has been a significant medium in my political information gathering throughout the election campaign….. I have noted that some candidates have not  engaged with constituents in that space – I think a little remiss in this day and age. Some have, only three candidates have a twitter profile,and only one seems to be engaged with the public in twitter….. releasing new information regularly about positions and views.

I have contributed to the general community discussion by highlighting rural mental health issues on local abc radio -listen here to  20 issues in 20 days – mental health  podcast: http://www.abc.net.au/local/audio/2013/08/26/3833847.htm?&section=news

I have made an authentic attempt to inform myself (and others) of key underlying issues about rural mental health generally, especially  in regard to the real life experiences of people in New England electorate, without any coupling to a particular political persuasion. I don’t think there will ever be vast amounts of money to solve mental health problems in the bush – BUT I do hold out hope that we can use grass roots initiatives and community development/ social captical approaches to improve mental health and the environment in which people live in the bush – – I think nurses are pivotal for progress in that regard…. I’m not looking for quick fixes, glossy media moments about shiny new things – but I am looking for meaningful and innovative progress that is driven from a rural genesis…. and my voting decisions are influenced by this.

My vote this election is influenced by my experiences as a rural mental health nurse. After a great deal of consideration – In the New England seat for me that will mean House of Rep’s – Vote 1 Rob Taber Independent; Senate – Vote 1 Australian Greens. I hope that this continues to develop stronger rural mental health support to rural people in the region where I live, work, help and nurse.

I guess some people will think it odd to be so candid and transparent about voting – but, in doing so I hope this conversation helps others consider carefully how they will vote and the impact that their vote will have on the mental health of rural people too. I think it is part of my nurse character in some respects – coming up with new and vulnerable ways to advocate for the rural people that I have served in my nursing career so far, and demonstrating that I have really put some thought into the privilege that it is to vote in Australia. I will be interested to hear views from others – and especially rural mental health workers!