The future of mental health

Intro:
Hello and welcome to the CPA Australia podcast, your weekly source of business, leadership, and public practise accounting information.

Gloria Sleaby:
Hello. My name is Gloria Sleaby. I'm an FCPA with experience in the primary and community health care sector. My current roles include director, deputy chair, and chair of the community engagement committee at DPV Health, advisory council member of the mental health complaints commission, and previous role at Victorian Divisional Counsellor at CPA Australia.

Gloria Sleaby:
A man who needs no introduction is Professor Allen Fels AO, mostly known for his role as the chairman of the Australian Competition and Consumer Commission. He is the former chair of the National Mental Health Commission. He currently chairs the Australian Government Migrant Workers Taskforce, is patron of Mental Health Victoria, and a patron of Mental Health Australia. He chairs the Haven Foundation. Since July 2018, he has been a member of the board of Mind Australia with which the Haven Foundation merged in 2018, and he is currently one of the four commissioners in the Victorian Mental Health Commission which is now underway. Welcome, Allan Fels.

Allan Fels:
Thank you very much.

Gloria Sleaby:
Professor, you are a well-known competition and consumer advocate. How did you become interested in mental health issues?

Allan Fels:
Personal experience. My daughter Isabella, my older daughter has schizophrenia. She had a very difficult childhood. She engaged in quite bizarre behaviour, had trouble forming relationships with other people of her age even though she's a very nice and peaceful person. But at 25, she had a really serious psychotic attack. She had terrible noises in her head, voices shouting at her, gunshot soundings in her head, a lot of delusions and hallucinations. That was initially tackled by medicine. She had some further relapses.

Eventually, she actually had some ECT, electronic convulsive therapy to get her back onto the path. To this day, she has problems. She takes medicine, is well looked after, but the medicine's a very imperfect cure. It suppresses the psychosis, but there are many side effects that aren't dealt with by the medicine. She's obsessive compulsive, sometimes lacks motivation, does not have a well organised mind, has trouble with daily living skills, is very vulnerable. People like her are vulnerable to exploitation of many forms. She's not, but they may be vulnerable to self-harm. They need to be looked after.

Gloria Sleaby:
That must make it very difficult for you and your family. You say that mental health is running at a fragmented fashion. Do you believe that's because of the funding or is it because of the private versus public? And how do you believe it should change?

Allan Fels:
Well, that's a huge ... There are a huge set of problems in mental health. Very fundamentally, it's not a very high priority of governments or the community. There's quite a bit of stigma, discrimination. It's not a very popular illness. If you talk to ministers, they'd prefer to put their money into less unpopular things. So the degree of support is not that strong, needs to be stronger.

Allan Fels:
Then on top of that, the system is not very well organised in numerous respects. There's too much effort put into what happens when people fall over the edge. It's a cliff to the bottom of the cliff. Then resources go into hospitals, acute care, and so on. Maybe not enough, but that's where there's a big concentration of resources. There's insufficient spend on trying to stop them from falling over the cliff, on prevention and early intervention. That's one of the misallocations that goes on. The system is not well integrated or coordinated in a whole lot of ways, and there are many other challenges for the system.

Gloria Sleaby:
So how do you feel your experience working with government and business can be used to improve these challenges that you say we are facing in mental health?

Allan Fels:
Well, with government there is some scope to get them to improve the system of organisation. At the National Mental Health Commission, we did quite a lot on how to redesigned the Commonwealth parts of the system. The Royal Commission is going to take a look at it in Victoria. The Productivity Commission's also doing an inquiry, more into the economic aspects of mental health. We'd like to get mental health on to the reform regime of the core economic departments like Treasury, Finance, Prime Minister's premier and cabinet, and so on. Not just health matter, but recognition of the very big economic benefits that would flow from getting an improved mental health system. So that's one stream going on the commissions. The Victorian Commissioner is just Victorian, but it may have some national effects.

Gloria Sleaby:
Who decides whether the commission should be a Royal Commission that includes all of the states of Australia, or just the Victorian Commission? And why aren't we having one that includes all of the Australian states coming from the situation where we know that it's endemic throughout all of Australia that at least one in five will have a mental health illness during their lifetime.

Allan Fels:
That's right. There's a very big incidence of it. As you say, one in five will be affected in any year. One and two just about in their lifetime. Three to four percent have got really serious persistent mental illness, things like schizophrenia, bipolar. Another 15 percent have got very substantial problems of mental health, ranging from fairly serious to moderate, to mild.

Allan Fels:
Now, against that background, you ask, well, isn't it a national problem? Well, we are a federation and one of the many challenges ... It's not the only one by any means. Is the division of responsibilities. So, in the broadest possible terms, you could say there are three stages. One is primary. You go to a GP or a psychologist. That is more or less Commonwealth. And the Commonwealth also picks up on the provision of drugs, pharmaceuticals. Then there's a middle stage, a middle bit, which most people think is under done, and that's community mental health services doing other things that might keep people out of hospital, like housing. And then there's a final bit, acute hospital, so that's state. The middle bit is a mixture of Commonwealth, state, and it is the weak point of the whole system. So that's why we don't have one national approach. And I wouldn't want to say it's the biggest problem, but it is a problem, the Commonwealth state interaction.

Gloria Sleaby:
So would it not be better to have a coordinated approach whereby, for example, if Victoria did some of the work and then New South Wales did some of the work and then we had national reform? Is that something that

Allan Fels:
Yeah, well it would be ... In some ways it would be good, but the states say, "Well, the hospital bit, that's ours. We don't want the Commonwealth taking it over." And it is true also that there are local solutions needed for a lot of those things. Commonwealth in some respects has tended to have the helicopter approach. It decides from time to time to sprinkle money around the country, dropping it out of a helicopter, wherever it lands, and things could be targeted better to local needs. That actually takes you below the state level down to local, and also might take you into regional approaches.

Gloria Sleaby:
So Australia is also holding a Royal Commission into the provision of aged care. Do you believe there are likely to be similar problems to the mental health sector? Have you been following the Aged Care Royal Commission?

Allan Fels:
Yes, I think there are somewhat similar problems. It's possible they'll be getting more complaints about how the system works, and maybe we will. We're looking especially at policy questions. I just want to comment on aged care and mental health problems. The bit of aged care of particular concern to me is the fate of older people who have had mental health problems all their life. What to do with the mentally ill when they get old. That's a very special and difficult problem, needs a lot of attention. Now, a slightly separate problem is the dementia problems that occur in old age, and there are no slick, easy answers to that. But to some extent, the aged care system tries to take care of the dementia issue, but they do tend to merge into one another.

Gloria Sleaby:
You head the Australian government's Migrant Worker Taskforce following exposure of underpayments to many migrant workers working in areas such as fast food and retail. The government has accepted in principle all 22 recommendations from the taskforce, which include much tougher penalties. Were there any surprises for you in what the taskforce discovered?

Allan Fels:
Well, first of all, there's the extent of the problem. We had a sense from experiences with 7/11, which occurred before that, that it was probably wide spread. But once it became a whole of government, whole of Australia inquiry, we learned more about the systematic widespread nature of the underpayment problem, and also some sense of the sectors in which it occurred most. And so, some of the solutions are targeted to particular sectors. Others are more general.

Allan Fels:
What I was a little bit surprised about was that this is an area where law enforcement has been a little bit equivocal. See, some areas of law enforcement ... The ACCC, there's a law that's applied to police, etc. In the employment area, there's a bit of a bipartisan understanding that we may not go as hard on law enforcement as you would like. There's been a bit of a reluctance to see heavy sanctions applied in that area. So for example of the fair work ombudsmen, I wouldn't call it the fair work police or the fair work enforcement agency. Ombudsman. That means when someone's breaking the law, sounds like we have a little bit of a negotiation.

Allan Fels:
Now, what we said in the report was that you need to make it more like business law. You need penalties that are the same. I mean, wage theft is as bad as or worse than consumer theft. So why not at least have that level of penalties applying? Why not apply the law as vigorously in that area as in consumer law? So, our recommendations flowed from that philosophy to bring it into line with the rest of law, and to get some of the other parts of government to help out a bit more. The education and agriculture and other sectors could do a bit more to help.

Gloria Sleaby:
So do you think then that same regulatory framework is what will be required with your role as one of the four commissioners in the Commission into Mental Health?

Allan Fels:
So the Commission has barely started and I feel happy to talk about my views on it, but it will be months before we arrive at a position. I'm not expecting it to have quite the same flavour as other Royal Commissions. The family violence one, it had a big effect. It did a good job. It's changed the way we look at problems. We have subtle differences with them. We have unsubtle differences with the Banking Royal Commission, and so on. And so, each one has to find a way forward that gets real progress made.

Allan Fels:
In this case, I think we have a combination maybe of a couple of things. One of them is that there will be complaints. Now we've already decided, we're not going to be a complaints tribunal. There is a mental health complaints commissioner who should be dealing with those things. But we will listen closely to the experience and concerns of people with mental illness problems.

Allan Fels:
But there's a big policy making role that we have, albeit somewhat targeted to state level issues but not really. We're trying to look at things more generally. So there will be a big policy component, and not different in some ways from how other Royal Commissions operated, which were more involved in judicial type investigations. At the extreme, take the Lawyer X Royal Commission. That's a very legal and understandably legalistic probing into certain matters and behaviour by an individual, individuals, its impact on justice, and it needs a highly legalistic approach. Ours does not really require a great deal of legalism. The government has nevertheless wanted us to be the Royal Commission, because that's the apex of inquiry methods. Shows its importance. It does mean we've got a lot of power to get data if we want to.

Gloria Sleaby:
So if you have the power to get the data, how will the Commission take into account the findings and recommendations of existing reports into the mental health system, such as the right to be safe, report intersexual safety in acute inpatient units, and other themes from the complaints that can be seen in the Mental Health Complaints Commission annual report?

Allan Fels:
We'll be looking at every report. There've been a great number of them.

Allan Fels:
At the same time, the premier has invited us to think very deeply about the fundamentals of what constitutes a good mental health reform system. So, the right to be safe is one of quite a few reports we're trekking through, and figuring out what would be productive for us to look at. The terms of reference do specify we take a system look. They do indicate we go beyond immediate mental health treatment in the medical sense. We might look at the prisons problem, for example. The intersection of the justice system and mental health. There's questions about the workforce that someone needs to look at, and no doubt we will. There's intersections with housing. So, we're tending to look fairly broadly at the whole system, and then we're going to focus on a few tough bits of it and go into them in some depth. We haven't really decided much at this stage, but I would expect we're gonna look fairly hard at the intersection with justice, for example.

Gloria Sleaby:
So then, what are your thoughts on the consumer's voice? And how have you seen consumers input, shape government and business, and how can the mental health complaints commissioner support influence decision making?

Allan Fels:
Well just at a very general level, we've not seen that much consumer or carer involvement. It tends to be supply-side driven by provider-driven, and I can understand that in one sense. But it would be better if we had a stronger, more effective consumer and family voice. Families are really important. They're the ones that fall with the lifelong commitment to unconditionally helping the person in their family, and they're the ones who also have the continuous contact with knowledge and understanding of them, which a set of caseworkers, one after the other, don't get a whole of life feel about a person. So families can contribute a lot. The system doesn't encourage that enough. And there's also insufficient participation and activity by people with lived experience of mental health as well, and we need to work on mechanisms to improve that.

Gloria Sleaby:
So I understand that unfortunately there was no consumer commissioner on the mental health commission, but could there still be scope for enhanced participation or partnership in an expert advisory council and making it accessible and supportive for consumers?

Allan Fels:
Well, there is firstly a special scientific committee headed by Professor McGorry who's encouraged to take on some commissioners who would look at some of those things. But in any case, we have to look at that fairly hard. I don't classify myself as a consumer but as a family carer person, feeling if you like that dimension of it. And one of the commissioners had some lived experience, I think, but we're not saying that's a consumer rep. But there are many ways of taking account of the consumer side. For what it is worth, in all the previous work I've done, there's been a very heavy emphasis on the consumer perspective. So I hope I can add a little bit to our work on that. And in any case, it's getting out there and talking to them that really counts.

Gloria Sleaby:
So what advice would you give CPA members? How might people doing financial tasks work with other stakeholders to improve outcomes and also just to improve their own health and the health sector in general?

Allan Fels:
Well, above all, they should look at mental health challenges in their workplace. Many businesses are aware of the problem. They don't quite know what to do. There is some guidance, including on the National Mental Health Commission website, and other sources about, how do you deal with the difficult problems at work? Whether it's you as a person or whether you're managing and you have some mentally ill people working for you. And the answers are pretty general at the moment. They include better work design, having greater transparency and openness to mental illness, recognising it's just an illness like any other that needs treatment, protocols for helping people come forward and disclose that they have mental health problems, recognising the sort of support they need. There is a vast agenda there that needs to be addressed by every business in the land.

Gloria Sleaby:
So what would you like to see happen now?

Allan Fels:
I want to see stronger community support, stronger government support. The media could cover it a bit better. Actually, what happens there is they have tried to improve their coverage, but every so often there's some disastrous outcome that sets back the cause. I would ask that the media tries, when they're reporting a connection to mental illness and violence, to at least maybe report a bit of the circumstances. The problems don't arise from people who are being treated for mental illness. They arise from people who are not being treated for mental illness. They're the ones that can sometimes do some harm. It's just [inaudible 00:22:12] if the media explains that point, and a bit about the context of any person with mental illness who does something against the law.

Gloria Sleaby:
So how did you gain knowledge of the mental health sector to the point where you could actually influence decision makers?

Allan Fels:
Well, I interact with the system all the time through my daughter, so I know quite a bit about what it's like on the ground and I can convey that to people. I'm lucky enough to be on the big national bodies and the state body and so on. There are others who can't do that communication, but that's my good luck in some ways, that I one day see it on the ground and the next day said the big national issues.

Gloria Sleaby:
I would argue that's also our good luck, that we have you speaking on our behalf. So we're currently up to Australian Royal Commission number 136 into aged care, quality, safety and the Mental Health Royal Commission in Victoria. In the Australian system of government, Royal Commissions are the highest form of inquiry on matters of public importance and are typically called whenever there is ongoing impropriety, illegal activity, or gross administrative incompetence in areas of Australian life, and the cost of taxpayers can run into the billions. Do you foresee the need for any specific Royal Commissions in the near future? And should we consider a permanent rotation of commissions?

Allan Fels:
Well, let me just tell you an anecdote. Somewhat amazingly, I recently met David Cameron, David "Brexit" Cameron, who is an extremely smart and able politician and he happens to have made a little slip in the way he handled Brexit. But putting that little slip to one side, I mentioned to him on a Royal Commission, and he said, "Oh, we don't have them in England any longer." And I had two thoughts about it. He was implying there are better ways of doing things than Royal Commissions. But he was also, I think, a politician saying, "I don't like these independent bodies." So, there are probably two reasons they don't have them in England. The politicians don't like these independent bodies criticising or attacking, etc.

Allan Fels:
It is true that most Royal Commissions are about some impropriety, bad behaviour, scandal. Ours is less so. Ours is more about systematic problems in mental health and policy solutions. Far from we weren't listened to people. We've got an emerging programme of hearings to travel around the state to hear from everyone, particularly people with lived experience, particularly their families. But also, people at ground level in towns around Victoria tell us what it's like, and not just mental health service providers. It's interesting to talk to the police. The police spend a lot of time on mental health matters.

They find people in the streets, something has to be done about them. They are almost, maybe they are, the number one source of people going into hospital. The police find them on the streets. They need treatment. The police bring them in. And again, there are other bits of the system where it's just interesting to hear from them. So, consumers, families, yes. But also, people who are involved in the provision of health services or are in some way affected by them.

Gloria Sleaby:
So currently mental health is measured through the inputs. What outcome measures do you think we should be using as a type of, I suppose, resource funding for mental health?

Allan Fels:
So, you're right to say there's a lot of information about inputs, about what's spent on what, but very little on outcomes, whether people are improving or not. There's not much individual evaluation of programmes either. So, a few years ago, I had an expert committee which recommended some measures of outcomes, but nothing's happened about it. It was a co-ed committee. It isn't always that easy to measure, but we could get a lot more information about the psychological condition of people with mental illness. We could get a lot more about accommodation, about employment. There are a number of measures we could strengthen to get a better feel for how the mental health system and the people in it are going.

Gloria Sleaby:
And you'll look at including some of those outcome measures in

Allan Fels:
I'm sure we'll have a look at that on the Royal Commission, as will the Productivity Commission.

Gloria Sleaby:
So I just want to ask a general question around people with mental illness that don't have family and don't have carers. Will there be included in the Royal Commission what support systems we can put in place for those people?

Allan Fels:
Well, I've got two answers. I think something will be done about it, but I'd encourage anyone who wants to send in a short letter or a submission to the Royal Commission on mental health. At the time of this interview, we're doing right now, we've only been operating a few days, so I can't give you a lot of information exactly on how to do a submission. But the more we hear from people, the better.

Gloria Sleaby:
So from your experience in the sector, are there any organisations that you suggest people can go to for immediate help?

Allan Fels:
Well, if you've got serious problems, as you would know, whenever there's a mental health story on the media, they will normally put up on the screen who to go to. Lifeline, [inaudible 00:28:17], Beyond Blue, and yet others. That's if you've got immediate problems. Now, there are other needs that you may have. You may want to go to a GP. They may get you launched on getting some care for yourself.

Gloria Sleaby:
Thank you very much, Professor Fels. It's been an honour and a pleasure.

Allan Fels:
Thank you very much.

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