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The Missing Middle

10 January 2020

The Missing Middle

“Mental illness is more ubiquitous than cancer. How can we help the ‘missing middle’? People with mental illness struggle to find the quality of care they deserve. But there’s hope and a pathway for progress.”
- Prof. Patrick McGorry

MAAP were commissioned by Victorian Health and Human Services Building Authority (VHHSBA) to provide analysis, mapping, and learnings from case studies into the planning and development of mental health facilities in Victoria and to inform VHHSBA of opportunities for improvement in their current service model.

The investigation of these inquiries originates from a workshop held as VHHSBA on th 21st August 2019 to explore ideas for the provision and location of new infrastructure an subsequent discussion based on a review of initial findings.

Despite the policy of de-institutionalisation, which became a primary aspiration in Europe and North America in the 1970s and 1980s, and by Australia during 1990s and early 2000s, the move to provide community based services, the transfer of the majority of inpatient beds to mainstream (somatic) hospital sites has simply re-created the institution in another setting.

Furthermore, as new facilities have been progressively added to extant hospital estates they have taken up valuable space which would have been more productively utilised for hospital expansion and replacement.

The preference for single storey mental health facilities which eventually became “policy” in 2000s and the enhanced space standards that increased the size of the footprint required has resulted in significant parts of a hospital campus being compromised by a service which could be argued is better located elsewhere i.e. closer to the population it serves (“right place, right time”) or in a location at the edge of a hospital campus facing the community it serves.

One of the reasons given for “mainstreaming” was that it de-stigmatised mental health services by putting them on a general somatic hospital campus and presumably “normalising” them in a medical/clinical setting. A different philosophy suggested in the early days of de-institutionalisation was that by locating mental health services visibly in a normal street or suburb connected them with their community and could be identified as an important investment in their health. De-stigmatisation by familiarity. Furthermore by sharing part of the new investment with the local population by inviting them to access and use the facilities for community activities this would help them break down the barriers and provide a context for better education. Thirty years ago this may have been a stretch too far but in 2020 perhaps the time is right for another try?

A number of MAAP projects have included activity centres that provide out of hours access for the surrounding community and encourage participation in the running or the maintenance of the facilities. Caretaking, gardening, organising events with other institutions such as schools or sports clubs.

Read the full report here.

The Well Placed Hospital
The Well Placed Hospital

Acute Health

The Missing Middle
The Missing Middle

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