October 11 - 17, 2015: Issue 235

 New Mental Health Study Supports Planning and Innovation in Services for Northern Beaches: The Way Ahead

Sunrise on Pittwater - A J Guesdon picture. 

 New mental health study supports planning and innovation in services for the Northern Beaches: The Way Ahead

6 October, 2015

Mona Vale-based Partners in Recovery recently launched a new publication that shows the way forward for mental health and related services on the Northern Beaches. Called The Way Ahead, the publication presents and analyses data gathered from the first 21 months of Partners in Recovery’s operations. It is the first time this information has been made available, and it will support planning and innovation in mental health services in the region.    

Partners in Recovery is a program led in the Sydney North Shore and Beaches region by Community Care (Northern Beaches). It aims to support people in the region who are experiencing severe and persistent mental illness, and who have complex needs, by:

• Facilitating better coordination of clinical and other services to deliver ‘wrap around’ care individually tailored to each person’s needs;

• Strengthening partnerships and building better links between various clinical and community support organisations;

• Improving referral pathways that access the range of services and support needed by the PIR target group; and

• Promoting a community-based recovery model to underpin all clinical and community support services being delivered to the target group.

“This is the first time such data has been made available and we are encouraging both current and potential future partners in the mental health and related sectors to use it for their own planning, system and service innovation,” said Laurie Bassett, Manager of Sydney North Shore and Beaches Partners in Recovery. 

The data reveals: 

• Of the 554 referrals to SNSB PIR to date, 390 are from the Northern Beaches  

• 1300 people are estimated to be living with severe and persistent mental illness in the North Shore and Beaches region (SNSB PIR is funded to work with 504 people up to 3  June 2016);  

• More than 37% of SNSB PIR clients live alone (compared with the Greater Sydney average of 23%);

• More than 38% of clients are living with a mood disorder (while the Australia-wide self-reported rate is 4.5% of the population); and

• 30% of clients are living with schizophrenia and delusional disorders, often complicated by homelessness and drug and alcohol misuse (compared with 1.5% of Australians experiencing schizophrenia in their lifetimes).

“One of the most useful pieces of information to come out of this analysis was the identification of our clients’ specific, unmet needs – lack of meaningful daytime activities, help with psychological distress, need for the company of others, opportunities in employment and volunteering, and support for physical health,” said Laurie Bassett.

“We are responding with a variety of partnerships and projects, including the LifePlus life skills courses developed with Northern Beaches Community College, a specially-created program of yoga and mindfulness with the Yoga Foundation, the establishment of street soccer teams with SUPPORT Opportunity and Care Inc., a partnership with Homes for Heroes to support veterans of recent conflicts, and even the creation of carers’ and clients’ choirs. We aim not just to address mental health issues, but also to provide practical support to overcome related challenges such as physical health, homelessness and social isolation,” he said. 

Copies of The Way Ahead publication are available on request from Partners in Recovery. Telephone 1300 000 747, email partnersinrecovery@ccnb.com.au, or visit the web site at: www.partnersinrecoverysnsb.com.au  to download a copy

Some Extracts from the report The Way Ahead:

Partners in Recovery (PIR) helps people with severe and persistent mental illness, and associated issues. The highest number of referrals in the Northern Beaches region came from:

1.  Manly

2.  Dee Why

3.  Narraweena. (Mosman ranked number 4, then Brookvale came in at number 5). 

• Our data indicates the top 5 unmet needs among clients are:

1. Meaningful daytime activities (in Northern Beaches, this unmet need was greatest in Manly, Dee Why, Brookvale, Narraweena and Seaforth)  

2. Help with psychological distress (greatest unmet need in Manly, Dee Why, Brookvale, and Seaforth)

3. Social contacts (greatest unmet need in Dee Why, Manly, Brookvale and Narraweena)

4. Employment or volunteering opportunities  (greatest unmet need in Manly, Dee Why, Mona Vale, Brookvale and Narraweena)

5. Help with physical health issues (greatest unmet need in Dee Why, Brookvale, Manly and Seaforth) 

•   Three of the five unmet needs (above) are related to social isolation. This, along with drug and alcohol misuse, financial stress and homelessness, are directly related to mental health issues in the region. Also worth noting:

o   Manly and Dee Why  have very high proportions of single person households (31% and 25% respectively) vs. the Greater Sydney average of 23%

o   Housing NSW says 70% of renters in Manly are on low or moderate incomes, and considered to be in housing stress. 

•   More than 38% of our clients are living with a mood disorder vs. the Australia-wide rate of mood disorders being 4.5% 

•   30% of our clients are living with schizophrenia and delusional disorders, compared with an Australia-wide rate of 1.5% likely to experience schizophrenia in their lifetime

About Community Care Northern Beaches

Community Care Northern Beaches (CCNB) is a not-for-profit, non-religious organisation that was established in 1994 and is funded largely by state and federal governments. CCNB supports older people, people with a disability, people with a mental illness, people with dementia and the carers of these people – all living in the Northern Sydney region. 

The organisation has 50+ staff and manages more than 20 programs, all aimed at helping people who are vulnerable to maximise their independence, wellbeing, and participation in the community. CCNB specialises in providing holistic support for people with complex needs. In 2013/2014 its oldest client was 101 and its youngest was one year old. 

About Partners in Recovery

Community Care (Northern Beaches) (CCNB) was appointed in early 2013 as the agency to manage the Sydney North Shore and Beaches Partners in Recovery (PIR) program. 

SNSB PIR covers the following areas: Warringah, Pittwater, Manly, Lane Cove, North Sydney, Willoughby, Mosman and Ku-ring-gai.

PIR is a Federal Government program designed to support people experiencing severe and persistent mental illness with complex needs, and their carers and families. The program involves coordinating multiple sectors, services and supports to work in a more collaborative, coordinated and integrated way. CCNB’s role as a lead agency is to manage and coordinate these many relationships to benefit clients.

To contact Partners in Recovery please call: 1300 PIR (1300 000 747) or 02 9998 2900 or email: partnersinrecovery@ccnb.com.au


For decades James* lived with the fragmented thinking, hallucinations and delusions that go with experiencing schizophrenia without diagnosis or effective treatment. He is now 42 and his illness was only diagnosed a year ago.

James held down high profile positions in a demanding profession during his 20s and early 30s but as he grew older and work pressures increased, his thoughts and behaviour became increasingly erratic. Eventually he consulted a GP who referred him to a psychiatrist. However even after sustained consultation, a full diagnosis and an effective course of medication were never achieved.

As he experienced further episodes of psychosis throughout his 30s, James lost his job, his wife and his children – and the home where they had lived together in better times. After an episode which resulted in him being admitted to a psychiatric ward for a month, James emerged with a diagnosis and a new medication. Another benefit of his hospitalisation was a referral to the Partners in Recovery (PIR) program by a psychiatric nurse.

Following intake, James was paired with a Support Facilitator at Uniting Recovery.

“My Support Facilitator is much more than a coordinator of services for me,” said James. “He is himself a source of support, someone I can always rely on to be available as a sounding board. We regularly meet for coffee and a chat.”

PIR supported James to:

Link up with a Support Facilitator at Uniting Recovery;

Work with his Support Facilitator to develop a comprehensive care plan;

Obtain financial counselling and tax agents to organise his financial affairs and start paying down debts;

Gain communications support and advocacy in dealings with psychiatrists and other mental health professionals;

Find a psychiatric nurse to administer his medication – a monthly injection;

Obtain appointments with an occupational therapist who is helping him develop mindfulness;


Link up with training organisation in order to prepare for new employment

Although highly skilled and experienced in his original profession, James’ mental health is such that he cannot hold down a full-time job. He is now retraining as a barista – a role that would combine his love of good coffee with the opportunity to reconnect with people on a professional and social footing. James is also now able to see his children regularly.

“Overall my experience with PIR has been very positive, and a lot of aspects of my recovery so far would not have been possible without this organisation. I’m extremely grateful for the work PIR does,” said James.

* Names throughout this case study have been changed to protect the client’s privacy.