Mental health and human rights in regional Australia in 2005
|Dr Sev Ozdowski OAM,
Human Rights Commissioner and
Acting Disability Discrimination Commissioner
Small Towns Conference
Centre for Sustainable Regional Communities La Trobe University , Bendigo 11 July 2005
Mr Johnathon Ridnell, ABC Regional Radio
Dr Maureen Rogers, Research Fellow, Centre for Sustainable Regional Communities
Ladies and gentlemen
I would like to begin by acknowledging the traditional owners of the land on which we meet, the Jaara people, and pay my respects to their elders both past and present.
I follow this custom wherever I go to speak in public. I think recognising Australia 's indigenous peoples and their prior ownership of this land in this way is more than just good manners. It is an important part of recognising our diversity as a nation.
Of course, there are also other important elements to that diversity in our communities.
25 per cent of us were born overseas, and may still have foreign-sounding accents like mine, even after decades as an Australian resident and citizen.
People who live in regional Australia understand of course that the real communities of regional Australia have always been more diverse than the stereotype of the bushman as a bronzed Anglo-aussie.
Here in Victoria we can think back to the diversity of the original "diggers" on the goldfields. I read recently that only two of the Eureka miners were Australian-born, the others coming from all over the world. Certainly, among the leaders at Eureka , I expect that Raffaello Carboni had an accent at least as strong as mine. Even Henry Lawson, born on the Australian goldfields, should really have been known as Henry Larsen after his Norwegian father.
The dimension of diversity I want to talk about today, though, is disability, as an essential element of our experience in human communities, and as something it is essential for communities and governments to acknowledge and respond to appropriately.
In particular, I want to talk about mental illness and how Australian governments respond to it, and particular difficulties facing people in regional areas.
Human rights: ivory towers or grassroots realities?
One reason I want to focus today on disability in talking about human rights in regional Australia is that for the last four and a half years I have had the role of acting as Disability Discrimination Commissioner as well as my substantive appointment as Human Rights Commissioner.
But I also think that talking about human rights issues in relation to disability, as it is experienced in local communities, helps us to talk about human rights in terms of realities and not just in terms of principles.
After all, what is the connection between the Universal Declaration of Human Rights, and other human rights documents adopted by the international community through the United Nations, and community life in a country town?
Are these just different worlds, one for unrealistic idealists perhaps and one for the real world?
As you may know, Dr Evatt, an Australian raised in the NSW regional centre of Maitland, was President of the United Nations General Assembly when the Universal Declaration of Human Rights was adopted back in 1948.
In the historical drama "The True Believers" Evatt was presented as saying, quite despairingly, after coming back from the United Nations to Australian politics: "Over there, you can build a new Jerusalem. Here, you get to open the Wagga Show."
Many people may see this sort of yawning distance between human rights ideals proclaimed in New York and Geneva and Vienna , and local realities in their own town.
But obviously, historical drama is not always the same as history. I don't think that Dr Evatt really thought like that about the value of local compared to global activity.
In any event, my colleagues and I certainly do not mistake the United Nations for some sort of heavenly kingdom or world government handing down wise decrees to the rest of us.
I admit that advocates of human rights can sometimes sound like that, or like the disciples of a new secular religion. But I don't think that my job in promoting awareness of human rights is really about passing on revealed truths and mysteries or commands, from the world of gravy trains to the world of road trains.
Human rights and democratic processes
Actually, it is more the other way around.
Human rights law calls on governments to use their resources, and to exercise their powers and also to restrain the exercise of power.
But the point of all this in the end is not really about governments.
It is to ensure greater freedom and opportunity for human beings to fulfil their own diverse needs and aspirations, as individuals and in communities.
This can only happen if people in every nation and every community can make their own voices heard and if governments are accountable for what they do in response to these voices.
I grew up in a society where you could be put in prison for trying to speak about pollution of the local river, or for trade union activity in the local factory, and where it was simply impossible to stand for election against the government candidate.
That is what we were given by radical idealists who had been absolutely corrupted by absolute power.
So when I speak about the need for better protection of human rights in Australia I do not at all mean to undervalue the achievements of democratic institutions in this country, national, state and local.
In a country like the one I had to leave, the first task of human rights advocates is to achieve democracy.
In a country like Australia there are still important and necessary tasks to make democracy more complete, and make sure that governments are accountable for responding to the needs of people whose needs and voices can be overlooked in an era of mass media and mass politics.
HREOC's National Inquiry on Mental Health and Human Rights
One of the things we have tried to do through the Human Rights and Equal Opportunity Commission's processes is to provide forums for the voices of people who are disadvantaged and have difficulty in being heard and being included.
This brings me to the subject of mental health, and recent work I have been involved in with the Mental Health Council of Australia.
Back in 1993, my predecessor as Human Rights Commissioner, Brian Burdekin, released the report of the Human Rights and Equal Opportunity Commission's National Inquiry into the Human Rights of People with a Mental Illness.
This inquiry was carried out over several years including hearings conducted around Australia , hundreds of submissions and extensive research.
The findings of the HREOC Inquiry's two volume report may be briefly summarised as follows:
The Inquiry found that people affected by mental illness suffered from widespread systemic discrimination and were consistently denied the rights and services to which they are entitled.
The Inquiry recommended a major government effort to redress negative community attitudes towards people with a mental illness.
- The Inquiry found that although the movement towards community care and mainstreaming of mental health services had reduced the stigma associated with psychiatric care, in general the money saved by deinstitutionalisation had not been redirected into mental health and related services in the community.
- The inquiry found that health services and other services which would enable people with a mental illness to live effectively in the community were seriously under funded or in some areas just not available at all.
- Crisis services were found to be inadequate.
- Treatment and discharge planning was found to be in need of major improvement.
- Mental health professionals and allied staff working both in institutions and the community were found to require education and training in the delivery of community based services, and needs for improved education and training were identified throughout the sector.
- The Inquiry also recommended added emphasis in health budgets for prevention and for mental health research.
- Governments were found to be relying increasingly on NGOs to provide services but to be treating NGOs as peripheral in the allocation of funds.
- Accommodation for people with a mental illness was found to be particularly inadequate, with government housing support programs either excluding people with mental illnesses or failing to address their specific needs. The inquiry found that the absence of suitable supported accommodation was the single biggest obstacle to recovery and effective rehabilitation.
- In the employment area, people affected by a mental illness were found to be disadvantaged by negative attitudes, a lack of awareness of means of accommodating employees with a psychiatric disability, and by inadequate vocational and rehabilitation services.
- Families and carers were found to be badly overstretched and insufficiently supported. As well as improved crisis facilities and other community mental health services the Inquiry recommended better information for carers and greater provision for involvement in decisions.
- Mental health services for children and young people were found to be seriously under developed. There were also recommendations for improvements in services for women.
- The Inquiry also made recommendations on culturally appropriate services for Aboriginal and Torres Strait Islander people and people from non-English speaking backgrounds.
- Specialist services for the many thousands of Australians affected by mental illness and some other form of disability were found to be almost non-existent, and services in either the mental health or disability sectors to be inadequately prepared to deal with the needs of this group, with the result that people with dual or multiple disabilities were often bounced from agency to agency without finding anyone who would assume responsibility for care or support for them.
- Laws regulating mental health services were found to be badly in need of reform.
- On one hand, laws failed to recognise sufficiently the principle of applying the "least restrictive alternative" and gave wide discretionary powers of detention without sufficient provision for review of decisions for detention or compulsory treatment. Yet on the other hand there was inadequate provision for treatment as a voluntary patient, much less a recognised legal right to access treatment.
- Laws providing safeguards regarding hospital treatment generally failed to extend to community treatment.
- The relationship between the administration of mental health law and guardianship law was found to need further development to provide for appropriate decisions to be made on behalf of people at times.
- The Inquiry found that mentally ill people detained by the criminal justice system are frequently denied effective health care and human rights protection. Procedures for detecting and treating mental illness and disorder in the Australian criminal justice system were found inadequate in all jurisdictions. As to whether this last issue remains a problem, perhaps it is enough to point to the experience of Cornelia Rau as she was passed from police custody to immigration detention without her mental health status being properly determined, let alone without assistance being provided to her.
Governments did make major responses to the Burdekin Inquiry.
The Burdekin Inquiry clearly contributed to the development of the first national mental health strategy.
In particular, the Commonwealth Government allocated funds for the first time specifically for mental health services, and became involved in providing some leadership in the area through a collaborative National Mental Health Strategy, rather than just leaving it all to the States.
Federal initiatives in response to the national inquiry report included $200 million over 4 years for services either directly targeted at, or providing substantial benefit to, people affected by mental illness.
There were also substantial law reform initiatives.
Responding to continuing concerns
But from the time I commenced as Human Rights Commissioner in 2000, I was still seeing report after report indicating a situation of ongoing crisis in access to effective mental health services.
Ever increasing concerns were also being communicated to me by community members.
Let me say here that I am aware that in using terms like crisis, or neglect, there may be a danger of being seen to blame or lower the morale of people who are working extraordinarily hard to deliver the best outcomes they can for patients, families and the community.
Nothing could be further from my intention.
My purpose rather in talking about inadequate services and outcomes is to put the focus where it belongs, on governments which are still not giving enough priority to mental health issues - and on a community and political culture which allows them not to.
I was reluctant to commence yet another inquiry in this area and add to the pile of reports.
For some time people in the sector were saying that they actually did not want another inquiry because it would just put pressure on the people and organisations struggling to provide services and supports with inadequate resources.
Despite this I became more and more concerned that we needed again to undertake major work in this area as a human rights commission:
to refocus debate in this area as involving matters of human rights;
and to draw public and political attention to this experience as a means of promoting accountability and remedies where abuses or neglect of human rights were found.
Human rights instruments and mental health issues
A fair enough question to consider first, though, is the question of what does mental health have to do with a Human Rights Commission?
We are not the experts on diagnosis, or design and delivery of health services after all. What right or what jurisdiction did we have to conduct a national inquiry in the 1990s or to engage with these issues now?
The basic answer it that our jurisdiction is defined by reference to international human rights instruments; and our role is not to be the experts but to promote public debate and political accountability on how well Australian governments deliver on the commitments made to our people through support from the Australian Government for these instruments.
I referred earlier to the Universal Declaration on Human Rights.
Article 25 of that Declaration refers to the right to medical care and other necessary social services as part of a right to an adequate standard of living.
The Universal Declaration is not a binding treaty. But it is accepted around the world as a common standard for governments to strive towards and, in the case at least of prosperous countries like Australia , a standard that people should feel entitled to expect will be achieved.
In 1975 Australia agreed to become a party to the International Covenant on Economic Social and Cultural Rights, which is a binding treaty, and which provides in its Article 12:
The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.
More detailed guiding principles "for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care" were agreed to by the United Nations General Assembly in 1991.
The UN Mental Health Principles reinforce the rights enshrined in the International Covenants and provide valuable guidance as to how those rights ought to apply to people with mental illness.
Principle 8(1) makes clear that people with mental illness have the right to the same standard of health care as other ill persons.
Principle 14 states that mental health facilities should have the same level of resources as any other health facility.
Additionally, Principle 7 emphasises the right to be treated and cared for as far as possible in the community.
Principle 9 emphasises the importance of 'the least restrictive alternative' in relation to treatment.
We are also party to the Convention on the Rights of the Child which also recognises the right to the highest attainable standard of health and to facilities for treatment of illness and rehabilitation of health.
But as I have already said, to learn what are human rights issues in Australia we cannot just look to United Nations documents.
Ultimately we need to listen to the voices of people in our own community who are missing out on freedom or opportunities enjoyed by the rest of us.
With this in mind, I decided last year to join with the MHCA and the Brain and Mind Research Institute (BMRI) and conduct consultations with people in the mental health sector.
We wanted to provide a forum for the experience of people affected by mental illness, as patients, families, or carers, together with community and professional service providers.
These Mental Health Consultations involved, first, the convening of 20 open community forums in each State and Territory from July to October 2004.
Forums involved consumers; carers; general members of the community; advocates; clinicians and other service providers (such as general health and accommodation providers); emergency personnel (for example police); academics and administrators.
We also conducted individual meetings with specific community, professional and non-government groups, and received around 360 submissions.
Results of the consultations
The report of these consultations is now planned to be released in August together with comments from governments on draft reports provided to them.
It has taken longer than we originally expected to get this report finished simply because the amount of input we received and the amount of interest in the process was so large.
Some key points from the consultations were these:
- Those with a mental illness are still being blamed for being sick.
- Resources provided are simply inadequate to match the level of unmet needs and ensure access to treatment and services when they are needed.
- Accountability for money allocated to mental health services is seriously lacking.
- The most frequently mentioned gap in mental health services was the absence of early intervention and other specialist services, in particular for young people.
- All too often people are being told, in effect, to come back when they are really ill. It is a good time to look at prevention and early intervention, rather than face the high cost of the treatment, in the future. Australian mental health experts lead the way in developing early intervention programs for the mentally ill. They are being implemented overseas, but not in Australia .
- Despite increasing evidence of links between drug use and mental illness we still lack adequate mental health facilities to cope where a person also has an addiction.
- Also we still lack adequate facilities able to respond appropriately where a person has other forms of "dual diagnosis" such as an intellectual disability together with a mental health problem.
- In all States I received reports of children and young people being admitted to inappropriate adult facilities.
- Emergency services are overburdened and often inaccessible. Acute care services are too often simply missing, especially in regional Australia. This results in preventable death.
- Community supports likewise are seriously overburdened and unable to cope with the existing demand.
- A key priority is increased availability of supported accommodation and housing options. You cannot hope to restore mental health unless someone has accommodation they can feel secure in.
- While deinstitutionalisation has continued, there have still not been corresponding increases in supports for people with mental illness to live in the community.
- This problem is proportionally greater in rural and remote areas.
Rural areas: additional issues
It quickly became apparent in the consultations that while people living in capital cities had many difficulties in accessing the mental health care and support that they needed, those problems were exacerbated in rural areas.
Let me give two examples of the additional problems facing people in rural areas.
First, distances between available services and the people who need them have meant there is an over-reliance on treatment by phone - which is completely inadequate for many people with a mental illness.
State governments should ensure, at the very least, 24 hour direct access to mental health care units and mental health professionals in rural and remote areas.
Second, we heard that there were sometimes extremely long journeys for people needing acute care under conditions which were entirely inappropriate.
For example GP's may be required to over-sedate someone so that they can be transported by air. Or people who need medical assistance, not punishment, may be required to travel long distances under police escort - which is demeaning for the patient, distressing for families, and an unwelcome diversion of police from the jobs they are trained to do.
It seems clear that we will see these difficulties continue or get worse until governments at all levels make mental health care a higher policy and budgetary priority.
As I have said, the report of consultations has not yet been published.
But I can say that it makes the following recommendations (amongst others):
higher priority for mental health care at the State and Commonwealth levels
better collaboration between government, the non-government and private sectors and the participation of consumers and carers
additional programs and resources to attract and retain staff in mental health care services (particularly in rural areas)
better integration and training between the drug and alcohol and mental healthcare workforces
more early intervention programs.
The voices we heard in our national consultations seem to me to be saying that the needs above all are for better accountability and for significantly more resources. There must be more money put on the table.
Australia currently spends only about 7% of its health budget on mental health. By comparison, other first world economies are spending between 10-14% of their health budgets on mental health. New Zealand now spends twice as much per capita compared with this country.
This call from the grassroots for more resources is backed up by governments' own assessments. The evaluation of the Second National Mental Health Plan, published by the Department of Health and Ageing in March 2003, stated that:
While the aims of the Second Plan have been an appropriate guide to change, what has been lacking is effective implementation. The failures have not been due to lack of clear and appropriate directions, but rather to failures in investment and commitment.
A shorter way and plainer of saying that is to say that governments have not sufficiently matched their words with dollars.
Key conclusions of this evaluation were that:
- while there has been growth in mental health expenditure, this has simply mirrored overall health expenditure trends and is not sufficient to meet the level of unmet need for mental health services;
- while community treatment and support services have been strengthened, community treatment options are often still unavailable or inadequate, with growth in resources to the non-government sector in particular not having kept pace with their increased role;
- although access to mental health care has been improved, consumers are still frequently unable to access mental health care as and when they need to;
- in particular, follow-up care into the community after hospitalisation for an acute episode is often lacking.
In other words, other reports to governments have given the same basic story as we have been hearing in our consultations around Australia .
So I think it is clear that it is really time for action on these issues.
Although the report from our national mental health consultations has not yet been published, we have already provided a draft report to the Federal Government and each State and Territory government.
We have also provided extensive information on the consultations to the Senate inquiry on mental health services which was established following the revelation of the experiences of Cornelia Rau.
I have to say that I am quite hopeful that we may see a more effective response from governments to these issues than has been seen before.
Not because I expect governments to take instructions from a Human Rights Commissioner or to regard the Commission as the experts on everything.
But because I think that on issues of access to mental health services around Australia , we have helped to make the voices heard of people affected by mental illness - directly, or as family members or in providing care and support.
And in a democracy when the people make their voices heard anything can happen. Thank you.