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National Press Club (ABC News 24) -

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This program is live captioned by Ericsson Access Services. But throughout that period, he has also been a passionate advocate for reform in the mental health area of policy reform. And expressed considerable concern about, over the years, about the need for that reform. It's in that role today as the Chair of the National Mental Health Commission that he joins us. For those of us with severe mental illness, the treatment on mendle disorder, there's now overwhelming evidence that much greater attention needs to be paid to their physical wellbeing, with life expectancy of those suffering up to 20 years less than for those in the broader population. More than 50 health organisations, many of those represented here today, in fact, have come together in an attempt to address this problem. They used to report equally well, and to launch that report and what needs to be done, would you please welcome Professor Allan Fels.(APPLAUSE) Thank you very much. And I would like to acknowledge the Ngunnawal people and their elders and their community and pay my respects to them. I would also like to acknowledge persons with lived experience of mental illness. And I would also like to thank the Press Club for its great interest and hospitality in having speeches on mental health by me and by others. So, I'm going to talk about one topic. The general topic season, of course, that mental health is the weak point of Australia's generally good health system. But I'm going to talk about one of the more visible and, to a degree, more fixable aspects of mental health - the poor physical health and wellbeing of those with mental illness. And in doing so, on behalf of the National Mental Health Commission, I am proud to launch Equally Well, the national consensus statement on improving the physical health and wellbeing people living with mental illness. That's a statement of 53 organisations concerned with mental health. About the National Mental Health Commission, it plays a key role in mental health reform. First, it monitors and reports on the performance of the system. Second, it engages with stakeholders all over, but especially with persons with lived experience and their carers, and, thirdly, it provides advice to governments and the community, particularly about evidence-based ways of improving outcomes for people living with mental illness. I would just like to single out two contributions the commission has made. First, it has promoted the concept of a contributing life. Essentially, this means that people living with a mental health difficulty should have the same rights, opportunities and health as the rest of the community. Simply put, it means having a stable and secure home, not a temporary one, meaningful work, opportunities for education and training, good healthcare and support when needed, and connections to family, friends and community. All without experiencing discrimination due to having a mental health problem. In short, it embodies a life where people with mental illness are thriving, not just surviving. And this concept highlights the need for a whole-of-government approach to reform. That is, reform just can't come from health departments or housing detriments -- departments or employmenter education departments alone. We need a wider approach, a whole-of-government approach to the strategy and governance of reform. Sadly, that's not what we do have in Australia. We need to have an approach at national and state level that involves all parts of government, not just health departments, and we need leadership from the top as part of that. The second point is that the commission, in 2014, reviewed the mental health system as a whole. We found that while there is a substantial level of investment in the system, it is a system that is fragmented, siloed, hard to navigate, and with too little spend on investment and especially on investment in prevention and early intervention. In 2015, the government announced major health reforms drawn from our recommendations, and those reforms have fundamentally changed the way services are planned and delivered, and focus on delivering a more person-centred, locally based, stepped care approach to mental health and suicide prevention services. Reflecting the value they place on the role of the commission, the Coalition Government made a commitment prior to the last election that it would strengthen the commission. We look forward to an announcement about that. I believe it is imminent. Today, however, I want to discuss the physical health and wellbeing of people living with mental illness. It is shocking that even now, in the 21st century, with all our capabilities, with perhaps the best healthcare, one of the best health systems in the world, that people with a mental illness have much poorer physical health outcomes than those without mental health issues. And particularly those with a chronic mental health condition. What is highly distressing is that, on average, people with a serious mental illness are younger, between 14 and 23 years' younger, than the general population. And of great concern, that gap has been slowly widening in the last three decades. And there are some other alarming statistics to consider. First, four out of every five people living with a mental illness have a co-existing physical illness. Compared to the general population, people living with mental illness are two times more likely to have cardiovascular disease, two times more likely to have respiratory disease, two times more likely to have metabolic syndrome, two times more likely to have diabetes, two times more likely to have osteoporosis, 65% more likely to smoke and six times more likely to have dental problems. And they comprise about a third of avoidable deaths. But people with severe mental illness are particularly at risk. They are five times more likely to smoke, six times more likely to die from cardiovascular disease, even if they're aged between 25 and 44. Four times more likely to die respiratory disease. More likely to be diagnosed with diabetes or have a stroke under the age of 55. 90% more likely to be diagnosed with bowel cancer, if they have schizophrenia, 42% more likely to be diagnosed with breast cancer if they have schizophrenia. Why is that so? Well, suicide actually only makes a small contribution. It's other factors. Medications can in many instances move to weight gain, obesity, cardiovascular disease, metabolic syndrome and type two diabetes. Often, no action is taken to actively prevent or manage these damaging side effects, despite clinical guidelines to the contrary. Partly because it's a little unclear who's responsible - the physical or the mental health people. Poor access to services also contributes. That can be due to a lack of knowledge or ability or motivation to locate, to access, to travel to appropriate services. New models of proactive, integrated screening of health care would address those concerns. Affordability of high out-of-pocket costs can also limit access to screening, investigation, medication, or other prescribed treatments. Stigma and discrimination is also still widespread, particularly for those with serious mental illness, and can discourage individuals from seeking help. And health professionals still all too regularly demonstrate stigma and discrimination against those with mental illness by ignoring them or by dismissing or diminishing the symptoms they report, by not investigating as frequently, or by not treating as assertively as they otherwise might if the person did not have a mental illness. And there is also so-called diagnostic overshadowing. In simple terms, if I have a sore back, then I'm taken more seriously than a person with mental illness with the same complaint. With the consequence that physical conditions can go undiagnosed and untreated, which can prove fatal. Quality of care can also suffer because health professionals don't feel fully comfortable often in knowing how to relate to persons with mental illness or how to explain treatment options or medications in a way that maximises understanding and compliance with treatment. And adding to that, physical health people may struggle to help people with mental illness, while mental health professionals may not pay enough attention to physical healthcare. And of particular concern is evidence of the inequalities and access to treatment in some of the most critical areas of healthcare, with individuals with schizophrenia at the greatest disadvantage. For example, some people, some patients with serious mental illness and diabetes are less likely to receive standard levels of care for their condition, just as patients with mental illness and cardiovascular disease are least likely to receive specialised interventions and some medications. And that can even - that differential can even extend into the surgical realm. Studies demonstrated that people with serious mental illness have higher rates of post-operative complications and higher post-operatively mortality. And other so-called risk behaviours are particularly high amongst those with mental disorders. Known risk factors, like smoking, alcohol, drug use, poor, high sedentary behaviour, and lower levels of physical activity contribute to poorer physical health. We know that when someone with mental illness smirks, there's often no effort made to discourage -- smoke, there's often no effort to discourage them. This may be well-intentioned but misinformed. "Shouldn't expect too much from people with mental illness." Or smoking is perceived to be their only pleasure in life, so why oppose it? In my view, however, this is yet another form of discrimination, not offering a treatment that could improve health and wellbeing and increase life expectancy. Simply because someone has a mental illness, that's unacceptable, to my mind. Now, there are many other big factors contributing to poorer health outcome as well. Almost the usual list when you're talking about mental health, of course, is inadequate housing. Lack of education. Social exclusion, low income, unemployment, exposure to violence and abuse, and intergenerational trauma. To name a few. Now, is it inevitable that people with mental illness will have poor physical health? The answer to that is a very big and clear no. Because we know that much of the link between mental illness and poor physical health is preventable. We just need to do more to prevent it. Health and wellbeing is a basic human right, and it's being denied to many in our community because they have a mental illness. The disparities in health outcomes for people living with mental illness that I have detailed to you today, with lower life expectancy, higher rates of physical health, are unacceptable. That's why the commission, aided by 53 mental health organisations and countless individuals, many here today, and whom I want to thank, led the development of Equally Well, the national consensus statement. We are all committed to putting mental health for people living with mental illness on an equal footing to that of people without a mental illness. Now, if we are to achieve improved health outcomes for people with mental illness, it would clearly require changes in the way the system works. And our statement calls for that in a number of respects. It calls for better collaboration and coordination between governments, professional bodies, social and community services and other leaders, in mental health, to make the physical health of people living with mental illness a national priority, and to address the many factors that face people living with mental illness at risk. One of the core problems we have called for is person-centred care rather than provider-centred care. A provider might deal with mental health, another with mental health, we want to see you start with the person and their whole set of needs, which include physical and mental health, and may extend to other matters around their wellbeing, and in the severe cases, matters like housing, employment, education, having some engagement in the community and so on. But if we could get a more person-centred base, that's gonna drive bringing the two treatments together. Now, also, the Equally Well statement challenges the low expectations that pervade the health system in terms of health outcomes for people with mental illness. They're quite low expectations. Now, not only can people with mental illness benefit from evidence-based interventions, they have the same right to high-quality, appropriate healthcare as everyone else. And our statement sets out practical approaches to addressing the problem of poor physical health of the mentally ill, including better prevention services, early treatment, better equity of access, improved quality of healthcare, care coordination, and better integration across physical health and mental health and other services. A word about Aboriginal and Torres Strait Islander mental and physical health. Just three points on that big subject. First, the life expectancy of Aboriginal and Torres Strait Islander people with mental illness is much less than for Aboriginal and Torres Strait Islander people without mental illness. Second, the emotional and social wellbeing framework stemming from Aboriginal and Torres Strait Islander culture is holistic and brings together physical and mental health in a way that mainstream approaches don't. Thirdly, I want to mention a passion of mine, that the Council of Australian Governments, COAG, Closing the Gap targets should include mental health targets. A word about economics. The OECD estimates the cost of mental health to developed countries is about 4% of GDP. There is scope for more and better investment in, and for much improvement in, the operation of the mental health system. Martin Wolf, the world's leading economics commentator, has said this: "Given the economic cost to society, including those caused by unemployment, disability, poor performance at work and imprisonment, the costs of treatment would pay for themselves." As to the total cost to the Australian health system of physical illness for people living with mental illness, it's been estimated at $15 billion, or about 1% of GDP. That includes the cost of healthcare, lost productivity and other social costs. I'd like to see reform of mental health to be seen as an important part of the economic reform agenda. The potential economic gains from improved mental health dwarf the possible economic gains from the economic reforms being talked about today. And they're also more politically achievable. Last week, a start was made. The Australian Conference of Economists made the economics of mental health a keynote session. There is a strong case for a reference of mental health to the Productivity Commission to get mental health on to the economic reform agenda. I want to mention the incredible contribution that carers of people with mental illness make. And particularly the economic contribution. An estimated 240,000 Australians care for an adult with mental illness but are not registered to receive carer benefits. According to a recent study by Mind Australia, it would cost $13.2 billion to replace informal mental healthcare with formal support in Australia. Nearly, again, 1% of GDP. Today there's not time to discuss the forthcoming Fifth National Mental Health Plan and Suicide Plan, except for one observation. One of my great disappointments at the commission over five years has been the slowness and resistance by governments to give enough priority to the production of measures of performance or measures of outcome in relation to the mental health system, strongly recommended by us since 2012. Just to prove it, one exemption to that general statement is that there has been a collection and recent public reporting on rates of seclusion, and that has generated a significant reduction in that restrictive practice. Shows the value of collecting and publishing outcome data. It's also important for the national mental health service planning framework to be publicly available. The reticents to publish this framework has held back public and political understanding of what is needed to address mental health. More broadly, we in theile mental health community know that, sadly, when push comes to shove, that when budgets are made, mental health, the poor cousin of health and social welfare, doesn't get the priority it needs. What I've found especially disappointing, however, is that following that, the failure even to publish data and information, that lets the community know the truth about mental health, and it could help make it a higher priority, doesn't happen. The National Disability Insurance Scheme is a great thing, and mental health should be included. There is early anecdotal evidence that, for many people with severe and persistent psychosocial disability, participation in the NDIS is resulting in more effective supports and services, better tailored to the diverse and specific needs of individual consumers. The commission, however, has also heard from multiple stakeholders at multiple meetings around Australia of many very serious issues and concerns expressed about its implementation in the mental health area. Today I refer to two issues only. First, there is a concern about the estimated number of people with mental illness and psychosocial disability who will not be eligible for support under the NDIS. Bear in mind this: The Australian Bureau of Statistics survey shows there are about 700,000 people with severe or psychotic mental illness, apart from the other 2 or 3 million with mild to moderate. 700,000. The issue estimate was that 64,000 people with psychosocial disability would qualify to receive individually funded packages for full rollout in 2019-2020. The Department of Health, not a bastion of radicalism, has estimated that it's more than 92,000 people. However, the commission, also not really a bastion either, thinks that both of these figures vastly underestimate the number of individuals with mental illness who need psychosocial support. And that there may be up to more than - up to or more than 200,000 people who will miss out on much-needed psychosocial support because they'll be deemed as not eligible under the NDIS. Incidentally, I discount claims that current enrolment numbers show the estimates were on target. The submission by the Victorian Government to the Productivity Commission spells out why that discount is something to be heavily applied. More people need to get in. Equally worrying is the fate of large numbers of people who are deemed to qualify, at best, for a lower tier of support. There are grave fears as to whether they will receive any significant support at all, and we deeply fear many people will fall into a big hole between the NDIS scheme and mental health schemes. The commission has raised this discrepancy with the Government, and I am very pleased, thanks to the efforts of Minister Hunt, that a funding commitment of $80 million was given in the Federal Budget to help bridge this gap. The $80 million is a good start, but it may not be sufficient to meet the need and it still needs to be matched by states and territories, who in some instances appear to have been withdrawing funding for psychosocial disability services as part of the transition to the NDIS. It's not just the NDIS we have to worry about. It's also the capacity of mainstream mental health services to support and complement the NDIS. If the NDIS is too restrictive, there will be a flood of people needing mental health services at great cost to federal and state governments. The second big and related issue is the assessment process for determining eligibility. The NDIS is principally designed for people with a physical or intellectual disability. Assessing their level of disability and the supports they require is relatively straightforward. In contrast, assessing the eligibility of people with mental illness and their level of psychosocial disability, and the supports they require, is frankly proven to be a major problem. For an assessment process dominated by physical and intellectual disability, the assessment process requires fundamental review. Just to take one problem, and there's a litany, many prospective participants aren't able to collect the evidence required to complete NDIS access and review processes. People with severe mental illness, particularly those on compulsory treatment orders, the homeless, people with a dual disability, those with little informal support network, are often unable to or reluctant to engage with formal support service systems, or they have no treating health professional. So, just for that category of people, there is a need for additional effort and outreach to help them access, understand and provide the information necessary for them to participate. The same for many others. Despite the NDIS commencing over three years ago, there is still no published eligibility criteria for people with psychosocial disability. Added to that, anecdotal reports indicate that the outcomes from the assessment process are somewhat unpredictable and seem quite variable for people with similar levels of psychosocial disability. All of this points to the need for the scheme to build much better the specialist skill capability needed to deal with people with mental illness, and also to consider whether a special gateway is required for people with mental illness to facilitate their entry to the scheme. At the moment, the big risk is that mental health becomes the poor cousin of the scheme, and is squeezed between an imperfect and incomplete NDIS and a contracting mental health system. I also believe that the NDIS, by all its virtues, for all the great things it's doing, fails to adequately address the housing support needs of people with mental illness, despite the provision in some cases for a payment of a so-called user cost of capital, which does make a contribution, but a limited one in this area. Well, in this speech, I won't go into details of our action plan. But I want to acknowledge that there is some promising and substantial work in this area from groups which are here with us today. I just can't mention all of them. I've picked two. There's the Healthy Active Lives program, the Hill program developed by Dr Jacky Curtis and others at the Bondi Psychosis program. There's also the Royal Australian and New Zealand College of Psychiatrists, who have produced an excellent report, Keeping Body And Mind Together. And I would like to acknowledge members of the Equally Well implementation committee, who are here today, who is co-chaired by someone from Charles Sturt University, and the ka chair of the National Mental Health Consumer and Carer Forum. They are joined by representatives from key stakeholders in the private, public and community sectors in the implementation committee task. And we also call on individuals and organisations across Australia to take action in their areas of influence. Many have already made the commitment and I believe more are on the way. Equally Well truly is a national statement of consensus. Today, there are 53 logos on the website, showing the support that already exists from the Australian and state governments, all of them, all mental health commissions, primary health networks, professional colleges, many high-profile mental health sector organisations. And we know of immense individual support for this tremendous but fixable challenge to the treatment of mental health. And in launching Equally Well, we wish to inspire a commitment to putting physical healthcare for people living with a mental illness on an equal footing with people with physical problems who don't have mental illness. Thank you very much. (APPLAUSE) Thank you, Professor Fels. It's time now for questions. Let me begin that process with a question. You made the point early in your speech that it's important for people with mental illness, particularly those with severe problems, to be able to thrive, not just survive. Are you actually saying, in fact, is it a fair characterisation to say that most people, if not virtually all, with severe illnesses are simply just surviving in our system today?