Parliamentary Committees

Social Development Committee: Comorbidity

The Hon. G.A. KANDELAARS (16:04): I move:

That the report of the committee, on comorbidity, be noted.

In June 2014, on a motion from the Hon. Kelly Vincent, the Social Development Committee resolved that the inquiry into comorbidity should commence. The terms of reference for the inquiry were advertised on 5 July 2014. In addition, the committee wrote directly to a number of individuals and organisations with expertise and interest in the subject matter, inviting them to provide evidence. Twenty-three written submissions were received and 15 witnesses gave oral evidence. The committee commenced its hearings on 15 September 2014 and concluded on 9 February 2015.

Comorbidity is essentially a clinical term that refers to the co-occurrence of two or more medical issues or more than one physical or psychological issue in the same person. A large number of people in the community experience comorbidity. They have increased rates of severe physical and mental illness, hospital admissions, mental health sectioning and increased rates of non-compliance with treatment orders. They have fewer social supports, use more public services and are more dependent on welfare benefits. They are at a greater risk of homelessness, incarceration, suicide and have a significant decrease in quality of life.

The committee heard from a number of witnesses that the current system fails to appropriately meet dual or multiple needs and that people with comorbidity do not receive appropriate treatment for a range of their conditions. Instead, more often than not, they receive treatment for the primary presenting issue. This could, and often does, lead to circumstances where they are shuffled between services or fall through the gaps.

Many of the barriers to optimal service provision for people with comorbidities can be linked to the separation of health, mental health, disability, alcohol and other drug sectors and their different institutional cultures. The committee believes that there is a need for greater coordination between these sectors. In a system constrained by availability of resources, improved coordination and the ability to treat people with comorbidity holistically would result in overall system savings. The committee believes that the introduction of consistent terminology and shared frameworks will lay the groundwork for consistency in policymaking, service provision and research leading to improved service provision and treatment efficacy.

It is essential that people with comorbidity experience an integrated treatment and service system that has a 'no wrong door' approach where they receive timely and appropriate screening and assessment and are assisted with all of their treatment and service needs. To guarantee that desired outcomes are met for people with comorbidity, funding and service agreements need to have outcomes that are clearly articulated and measured against performance.

The committee heard evidence that people with mental illness are significantly over-represented in the criminal justice system. Evidence-based research suggests that mentally ill people are two to three times more prevalent in prison populations than in the general community. The committee was concerned to hear that there are a significant number of forensic clients with comorbidity who are incarcerated, even though they have not been formally charged with an offence because of their inability to plead due to mental impairment.

Evidence shows that silos and overlaps are a consequence of different laws that may be invoked in response to a person with comorbidity. There is an overlap between the Mental Health Act, the Guardian Administration Act and the Criminal Law Consolidation Act. Individuals may also be subject to the provisions of the Public Intoxication Act.

The committee heard that multiple orders may be in place with compounding restrictions. For example, a person may be placed under a Mental Health Act order when the criteria for an inpatient treatment order or a community treatment order are met. The same person may also have a guardian or an administrator appointed under the Guardianship Administration Act. Should their behaviour lead to the involvement of the criminal justice system:

a person may be found guilty and sentenced; or

if the person is found by the court to be unfit to plead, or considered not guilty by reason of mental impairment, a limiting term may be set under the provisions of the Criminal Law Consolidation Act.

Other relevant legislation includes the Disability Services Act, which determines the funding and provision of disability services in South Australia, and the Supported Residential Facilities Act, which provides for the care of people living in this form of accommodation. Committee members are concerned that the application and potential overlap of these laws is often problematic for people with comorbidity.

The committee heard that the number of available forensic beds does not currently meet demand, even with the recent release of new beds at James Nash House. This means that there is an unknown number of forensic clients within the prison population. Committee members are concerned that timely and appropriate responses may not be readily available within the criminal justice system to provide for the specific needs of people with comorbidity. The committee believes that this is clearly an unacceptable outcome and has made recommendations in an attempt to rectify this situation.

The ability to respond effectively to comorbidity is linked to the availability of professional staff with expertise to assess and manage appropriate treatments and service responses. The committee heard that there is currently a lack of formal comorbidity training for professionals. Education and training is critical in repositioning the way in which services are managed for people with comorbidity.

The committee believes that there is a need to develop capacity within the disability, health, mental health and alcohol and other drug sectors to treat people and provide support for people with comorbidity. To avoid the use of restrictive practices, including restraints and seclusion, comorbidity education and training is imperative when managing challenging behaviours and episodes of care. The committee considers that mandatory training requirements for comorbidity should be written into appropriate legislation and further considers that measures should be introduced to improve comorbidity training and increase skills and knowledge in the area of assessing and treating comorbidity.

The committee noted that there was a lack of quantitative data in the evidence received in the course of this inquiry. The committee is aware that there is a need to collect more rigorous statistical data to better understand the level of need that exists with people with comorbidity.

In recognition of the key roles that family, paid disability support workers and others in the community play in supporting people with comorbidity, the committee endorses the need for access to relevant information and resources to aid this support. It is only through informed choices that individuals with comorbidity, their family and paid carers can ensure that they have the opportunity for a positive life experience.

Yesterday the Social Development Committee tabled the comorbidity inquiry report before this council. The report contains 40 recommendations intended to improve the service system for people with comorbidity, their family carers and paid workers, and for forensic clients with comorbidity in the justice system, including recommendations for legislative amendments.

Finally, I would like to take the opportunity to thank members from the other place who provided valuable input into the inquiry. I would like to thank Ms Katrine Hildyard, who was a member of the committee up until February 2015; Ms Nat Cook, who was appointed to the committee in February 2015; Ms Dana Wortley; and Mr Adrian Pederick. From this chamber, I would like to thank the Hon. Kelly Vincent and the Hon. Jing Lee.

Inquiries of this nature would not be possible without the valuable contribution of many individuals and organisations who gave up their time to come forward and give information. I would like to thank all those who presented evidence to the inquiry, either in writing or appearing before the committee. I should also mention the hardworking secretariat staff of the committee who provided valuable support to committee members during the course of this inquiry.

Debate adjourned on motion of Hon. J.S. Lee.