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Policy framework statement

The Mental Health Policy Framework specifies the legal, best practice, reporting and process requirements that all Health Service Providers (HSPs) must comply with in order to ensure effective and consistent provision of public mental health services across the WA health system.

Purpose

The purpose of this policy framework is to ensure:

service coordination and integration in the provision of mental health services
consumers of mental health services receive mental health care that is safe, effective, appropriate to their needs, timely and efficient
mental health consumers are informed about their treatment and involved in decisions about the treatment, care and support they receive.

Applicability

This policy framework is binding on each HSP to which it applies or relates.

Principles

The key principles that underpin this policy framework are:

Accessibility

Accessible and safe services that provide people experiencing mental health issues with timely treatment, care and support of a high quality, to promote recovery in the least restrictive manner that is consistent with their needs.

Accountability and improvement

Accountable services based on contemporary best practice and committed to continuous improvement.

Consistency

Consistency with State and Australian Government mental health policies and compliance with mental health legislation and standards, including upholding of the Charter of Mental Health Care Principles (Mental Health Act 2014, Part 4, Schedule 1).

Person-centred

A person-centred focus with a view to obtaining the best possible outcomes for people experiencing mental health issues, including by recognising diverse individual circumstances, life experiences, needs, beliefs, preferences, aspirations, values and skills, while delivering goal oriented treatment, care and support.

Legislative context

This policy framework is made pursuant to ss 26(2)(a)(c)(d) of the Health Services Act 2016.

The Health Services Act 2016 refers to policy frameworks in ss. 26-27 and s. 34(2)(c). Other relevant parts in the Act that relate specifically to this policy framework include ss. 44-45.

The legislation below, may also apply:

Mental Health Act 2014 and Mental Health Regulations 2015
Criminal Law (Mentally Impaired Accused) Act 1996
Guardianship and Administration Act 1990
Carers Recognition Act 2004

Mandatory requirements

Under this policy framework HSPs must comply with all mandatory requirements* including:

This policy framework is to be read in conjunction with relevant standards and guidelines mandated by other statutory bodies including, but not limited to, those required by the Chief Psychiatrist of Western Australia under section 547 of the Mental Health Act 2014.

Policy framework custodian

Deputy Director General

Enquiries relating to this Policy Framework may be directed to: PolicyFrameworkSupport@health.wa.gov.au

Review

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This policy framework will be reviewed as required to ensure relevance and recency. At a minimum this policy framework will be reviewed within two years after first issue and at least every three years thereafter.

Version	Effective from	Amendment(s)
33	30 April 2025	Amendment to MP 0063/17 Road-Based Transportation for Mental Health Consumers Policy. Amendment includes: Policy requirement 3.5 and related document section: 'WACHS Mental Health Transport Risk Assessment Form' for the WA Country Health Services (WACHS) updated.
32	14 April 2025	Policy review and amendments to MP 0062/17 Alcohol and Other Drug Withdrawal Managment Policy. Amendments include the following: Purpose section: updated to remove duplication of information and improve readability. Replacement of the term patient with individual. Inclusion of principles from subsection 3.1 of the policy with the addition of three new principles (trauma-informed, culturally competent, recovery-oriented). Policy requirements section: relocation of subsection 3.1 principles to the purpose section of the policy. Removal of ‘3.2 Practices’ heading, and content reformatted to improve readability. Addition of subsection 3.1 Reporting to state that HSPs must demonstrate compliance by completing a reporting template provided by the MHU; Compliance monitoring section: refined to improve readability; Supporting information section - removal of outdated supporting documents and the addition of supporting documents (Department of Health and Aged Care – Guidelines on the Management of Co-occurring Alcohol and Other Drug Mental Health Conditions in AOD treatment settings, Department of Health Western Australia – WA Aboriginal Health and Wellbeing Framework 2015-2030, The Australian Government Closing the Gap Implementation Plan 2023-2025; Definition section: update to ‘High medical withdrawal services’ to reflect the involvement of peer support workers, Aboriginal mental health workers and Aboriginal liaison officers. Inclusion of definitions of the policy principles that have been relocated to the purpose section.
31	4 October 2024	Rescindment of ‘Responding to an Allegation of Sexual Assault Disclosed within a Public Mental Health Service Policy' (Office of the Chief Psychiatrist, 2012) from the Mental Health Policy Framework. Contains outdated information and processes, that have been superseded by the Chief Psychiatrist’s Guidelines for the Sexual Safety of Consumers of Mental Health Services in Western Australia and Sexual Safety of Consumers of Mental Health Services Standard.
30	1 October 2024	Policy review and amendments to MP 0063/17 Road-Based Transportation for Mental Health Consumers Policy. Amendments include the following: Title updated from ‘Requesting Road-Based Transport for Mental Health Patients Subject to Transport Orders Policy’ to ‘Road-Based Transportation for Mental Health Consumers Policy.’ Purpose section amended to clarify the purpose of the policy, relevant legislation and other documents; Applicability section amended to clarify the scope of the policy and include a statement on contracted health entities; Policy requirements section amended to remove duplication, improve readability, and incorporate current advice about the involvement of police officers in mental health consumer transports. The following subsections have been inserted: Underlying principles; Determining the most appropriate means of transport; Using transport officers to undertake transport; Engaging the WA Police Force to assist with transports; Requesting road-based transports using a transport order; Transport orders involving aerial transportation; and Reception of mental health consumers transported under a transport order; Compliance monitoring section amended to align with mandatory policy governance requirements; Related documents updated to include transport risk rating forms; Supporting information updated to include ‘Mental Health Patient Transport contact information and referral processes’ and ‘Metropolitan Inter Hospital Patient Transfer Framework.’ Definitions section amended to include ‘absent without leave’, ‘authorised mental health practitioner’, ‘culturally competent’, ‘health professional’, ‘medical practitioner’, ‘mental health consumer’, ‘person-centred’, ‘recovery-oriented’, ‘restraint’, ‘staff member’ and ‘trauma-informed’. Definitions for ‘transport officer’ amended, and ‘Transport Order (Form 4A)’ and ‘Apprehension and Return Order (Form 7D)’ removed.
29	17 June 2024	Policy review and amendments to MP 0012/16 Mental Health Consumers Who Are Missing or Absent Without Leave Policy. Amendments include the following: Title updated from 'Missing Person Policy' to Mental Health Consumers Who are Missing or Absent Without Leave Policy; High-level requirements from 'Missing Person Policy' were transferred to the Purpose, Applicability, Policy Requirements and Compliance Monitoring sections of the 'Mental Health Consumers Who Are Missing or Absent Without Leave Policy; Operational requirements form the Missing Person Policy have been inserted in a new supporting information document: 'Best Practice Guideline: Mental Health Consumers Who are Missing or Absent Without Leave'; New Policy Requirements subsections have been included: Responding to Absence Without Leave and Missing Persons, Involving the WA Policy Force, Non-attendance Where Consumers are Neither AWOL nor Missing Persons, Training and Professional Development and Auditing and Analysis; New related document: 'Procedures for Involving Police When Mental Health Consumers Are Missing or Absent Without Leave'; Definitions for absence without leave, Apprehension and Return Order, diligent efforts, health professional, mental health consumer, public mental health service and WA health system have been added.
28	15 January 2024	New mandatory policy: Safety Planning for Mental Health Consumers Policy. This policy outlines the standards to ensure a consistent approach to protect the safety of mental health consumers. This policy supersedes the following Mental Heatlh mandatory polices: MP 0074/17 Clinical Care of People Who May Be Suicidal Policy, MP 0101/18 Clinical Care of People with Menal Health Problems Who May Be At Risk of Becoming Violent or Aggressive Policy and MP 0070/17 Mental Health Emergency and Follow Up Information on Discharge from Hospital Emergency Departments Policy.
27	21 August 2023	Amendment to policy framework custodian from Assistant Director General, Clinical Excellence Division to Assistant Director General, Strategy and Governance Division. The DoH Mental Health Unit has transferred from Patient Safety Clinical Quality Directorate, Clinical Excellence Division to Governance and System Support Directorate, Strategy Governance Division.
26	11 July 2023	Minor amendment to MP 0062/17 Alcohol and Other Drug Withdrawal Managment Policy. Inclusion of updated supporting information: Alcohol and other Drugs Withdrawal Managment Practice and Pathways.
25	1 November 2021	Rescinded MP 0069/17 Mental Health Consumer Medication Information Policy.
24	9 August 2021	Minor Amendment to MP 0155/21 - Statewide Standardised Clinical Documentation for Mental Health Services - addition of new supporting information to - 'Triage to Discharge Mental Health Framework for SSCD'.
23	30 June 2021	New MP 0165/21 Use of Physical and/or Mechanical Restraint during Road-based Transportation of Mental Health Patients Policy to supersede MP 0060/17 Use of Physical and or Mechanical Restraint during Road based Transport of Mental Health Patients.
22	28 June 2021	Major Amendment to MP 0062/17 v.2.0 Alcohol and Other Drug Withdrawal Management Policy: Policy transitioned to current Policy template; reviewed and updated as part of the 'Walk with Me Project', addition of new supporting information and minor edits to under the 'Purpose' and 'Policy' requirements sections. As a full review was undertaken, a new cycle will now commence.
21	17 June 2021	Major Amendment to MP 0099/18 Community Mental Health Status Assessments: Role of Mental Health Clinician Policy. Refer to the Document control section of the Policy for complete amendment details. As a full Policy review was undertaken, a new review cycle will now begin.
20	8 June 2021	Rescinded OD 0637/15.
19	17 March 2021	New MP 0155/21 Statewide Standardised Clinical Documentation for Mental Health Services to supersede OD 0526/14.
18	30 November 2020	Amendment to Policy Framework: Purpose, principles, legislative context and mandatory requirements updated to clarify the purpose and application of the Policy Framework. Hyperlinks to external resources updated.
17	7 October 2020	Rescinded Clinical Risk Assessment and Management (CRAM) in Western Australian Mental Health Services Policy and Standards.
16	29 July 2020	Major Amendment to MP 0063/17 Requesting Road-Based Transport for Mental Health Patients Subject to Transport Orders Policy.
15	4 September 2019	Australian Commission on Safety Quality in Health Care 2012 Ntl Safety Quality Health Service Standards removed as it is no longer current.
14	25 July 2019	Major Amendment MP 0101/18 v.2.0 Clinical Care of People With Mental Health Problems Who May Be At Risk of Becoming Violent or Aggressive Policy - see the Document control section of the Policy which articulates the nature of these amendments.
13	24 December 2018	New MP 0101/18 Clinical Care of People With Mental Health Problems Who May Be At Risk of Becoming Violent or Aggressive Policy effective from 1 January 2019.
12	22 November 2018	New MP 0099/18 Community Mental Health Status Assessments: Role of Mental Health Clinicians Policy, supersedes OD 0644/16.
11	17 October 2018	Rescinded OD 0635/13 from Mandatory Requirements.
10	17 January 2018	Rescinded OD 0596/15 from Mandatory Requirements, superseded by MP 0078/18 Medication Chart Policy (Mandatory Requirement under Clinical Governance, Safety and Quality Policy Framework).
9	10 January 2018	Rescinded Addendum to Mental Health Complaints Partnership Agreement between Health and Services Disability Complaints Office, Department of Health, Council of Official Visitors, Office of the Chief Psychiatrist and Mental Health Commission (August 2015) from Supporting Information.
8	21 December 2018	Updated Policy Framework Custodian. Changes were not made to Policy Framework landing page until 10 January 2018.
7	19 December 2017	Rescinded OD 0643/16.
6	13 December 2017	New MP 0074/17 Clinical Care of People Who May Be Suicidal Policy.
5	4 October 2017	New MP 0069/17 Mental Health Consumer Medication Information Policy, superseded OD 0591/15. New MP 0070/17 Mental Health Emergency and Follow Up Information on Discharge from Hospital Emergency Department Policy, superseded IC 0223/15.
4	10 August 2017	New MP 0062/17 Alcohol and Other Drug Withdrawal Management Policy.
3	9 August 2017	New MP 0063/17 Requesting Road-Based Transport for Mental Health Patients Subject to Transport Orders Policy superseded OD 0659/16 and OD 0664/16
2	1 July 2017	New MP 0060/17 Use of Physical and/or Mechanical Restraint during Road-based Transportation of Mental Health Patients Policy.
1	1 July 2016	Original version

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Approval

This policy framework has been approved and issued by the Director General of the Department of Health as the System Manager.

Approval by	Dr D.J. Russell-Weisz, Director General, Department of Health
Approval date	01 July 2016
Date published	22 November 2018
File number	F-AA-40152

Compliance

This policy framework is binding on those to whom it applies or relates. Implementation at a local level will be subject to audit.

Glossary of terms

Term	Meaning
Applicability	Under Section 26 of the Health Services Act 2016, policy frameworks may apply to: All Health Service Providers A type of public health service facility A type of public health service A type of staff member of a health service provider.
Health Service Provider	Means a Health Service Provider established by an order made under section 32(1)(b) of the Health Services Act 2016.
WA health system	Pursuant to section 19(1) of the Health Services Act 2016, means the Department of Health, Health Service Providers and to the extent that Contracted Health Entities provide health services to the State, the Contracted Health Entities.