Parliamentary Committees

Social Development Committee: Comorbidity

Adjourned debate on motion of Hon. G.A. Kandelaars:

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

(Continued from 9 September 2015).

The Hon. J.S. LEE (17:51): I rise to speak as the Liberal opposition member on the Social Development Committee to endorse the final report on the inquiry into comorbidity, which was tabled by the Hon. Gerry Kandelaars. Comorbidity relates to a complexity of circumstances, for example, where a person living with an intellectual disability is also experiencing mental health issues or chronic substance misuse issues. Each circumstance represents an increase in vulnerability. Thank you to the Hon. Kelly Vincent MLC for moving the motion for the Social Development Committee to inquire into this important and complex area.

The committee identified during our investigation that it is a significant issue that there is no agreed definition about what constitutes comorbidity in the Australian context. Not having an agreed definition means that there is a lack of shared knowledge, language, frameworks and agreed category of terms. That also means that there is no standard point of reference for researchers, professionals, service providers and other relevant stakeholders.

The committee recognises the need for the sector to come up with a common set of definitions of comorbidity so that it would result in improved data collection, improved communication and coordination between providers, a better understanding of the wider service delivery context, consistent screening and assessment tools, and the delivery of a comorbid service pathway to ensure that people do not fall through service gaps.

Comorbid mental health, physical health, intellectual disabilities and substance misuse disorders are associated with significant economic and human cost, to the individuals concerned and to the wider community. People who experience comorbid conditions face complex challenges in their daily lives. For example, they have increased rates of hospital admissions, they have increased rates of relapse, use more public services, are more dependent on welfare benefits, increased rates of unemployment, experience difficulty in maintaining social networks, and are also at greater risk of suicide and a greater risk of housing instability and homelessness.

The committee heard evidence from a number of witnesses who suggested that, commonly, people with comorbidity do not receive appropriate treatment for the range of their conditions. Instead, more often than not, they receive treatment for the primary presenting issue. This could lead to circumstances where a client is shuffled between services, falls through gaps, or enters the wrong doors. A number of individuals and organisations gave evidence to the committee that treatment services for people with comorbidity should be delivered by a single entity. The submission from the AMA made the point that there is no strong centre for intellectual disability in South Australia.

Throughout the duration of the investigation, the Social Development Committee put together a thorough recommendation list to ensure that a system could be developed in order for people with comorbidity to receive timely and appropriate screening and assessment and are assisted with all of their treatment and service requirements. The 40 recommendations developed by the committee provide a strong, broad and thorough outline of what is needed to achieve such results within the sector.

Having received 23 written submissions and 15 testimonies from witnesses, the committee expressed its appreciation for the valuable work of individuals and organisations that presented a comprehensive set of evidence on the challenges and the complexity of comorbidity and the desirable recommendations.

It has been a productive committee, and I thank the members serving on the Social Development Committee: the Presiding Member, the Hon. Gerry Kandelaars, and the Hon. Kelly Vincent in this chamber. I also thank the members in the other place: the member for Hammond (Adrian Pederick), the member for Fisher (Nat Cook) and the member for Torrens (Dana Wortley). Special thanks go to Robyn Schutte, the secretary of the Social Development Committee, and Carmel O'Connell, the research officer, for their wonderful work and continuous support to the members of the committee. With those remarks, I commend the comorbidity report to the council.

The Hon. K.L. VINCENT (17:55): In speaking to this motion I would like to first put on the record my thanks to the Social Development Committee secretary, Ms Robyn Schutte, and the committee's research officer, Ms Carmel O'Connell, for their work on this inquiry. I also acknowledge committee members, in particular the Hon. Gerry Kandelaars as the current presiding officer of the committee.

Members will recall that Dignity for Disability called for this inquiry into comorbidity (which is, generally speaking, the coexistence of two or more health conditions which, while different, may impact one another) because it was clear from our dealings with constituents that there was a broad lack of understanding about comorbidity in the general population, in the fields of disability and mental health support services provision and in the medical profession. The result of this lack of understanding, it seemed to us, was that people with more than one diagnosis were not receiving holistic treatment and support.

As one example of the lack of acknowledgement of comorbidity or dual diagnosis, I vividly recall a telephone conversation with a constituent some years ago who told me that her son who had autism was receiving treatment regarding his mental health. This constituent told me that when she tried to explain to the treating physician how her son's autism would impact the way he responded to certain forms of treatment regarding his mental health and that the treatment needed to be adjusted accordingly, the doctor replied with words to the effect of, 'I'm here to treat his mental health, not his autism.' To me, this is every bit as unhelpful as a doctor telling me, as a wheelchair user, that they are willing to treat me but they will not install a ramp at their clinic.

It was clear that this issue needed to be looked at in depth, and I am pleased that the Social Development Committee has given the parliament the opportunity to do so. The committee heard evidence from people either experiencing or people servicing people who experience a range of conditions, including intellectual disability, acquired brain injury, mental health challenges, chronic substance abuse, people on the autism spectrum, epilepsy, foetal alcohol spectrum disorder, compulsive disorders, and so on.

Although the committee's inquiry covered a broad range of conditions, unfortunately the experience of all people experiencing comorbidity seemed similar in terms of the challenges that they faced. Certainly, the lack of a consistent definition of what actually constitutes comorbidity was quickly identified as problematic, as the Hon. Ms Lee has identified before me. The report recommends further work at both the state and federal levels on getting a more consistent definition around which we can frame further work and discussion.

As the Australian Medical Association (AMA) pointed out to the committee, it appears that the main issues for people with comorbidity are:

the complex ways in which each condition can affect the other;

a lack of appropriate tools for diagnosis and to identify different issues for individual clients;

a lack of coordination between support services, making them difficult to navigate holistically; and

difficulty in accessing support services, including appropriate accommodation.

As a result, people with comorbidity experience significant disadvantage, including: decreased social supports; higher dependence on welfare; increased rates of hospitalisation, with longer stays in hospital; and being at greater risk of incarceration. All these things, of course, not only take a great social and emotional toll on individual lives but it is important to remember that they can also come at a great financial cost to the community, so I believe improving supports around those with comorbidity will benefit us all.

Given these concerns, much of the evidence and many of the recommendations of the committee centre around treatment options for people with comorbidity and how support systems respond to such diagnoses. Many of the report's recommendations centre on the need for greater collaboration at a government level between relevant ministers, namely, the Minister for Health, Mental Health and Substance Abuse and the Minister for Disabilities. The committee recommended greater collaboration between these departments to develop and implement greater resources. The screening and identification of comorbidity and a 'no wrong door' approach, creating a more streamlined and holistic treatment option for people with comorbidity was particularly identified.

The committee also heard evidence on the need for a cross-sector first response team, which would be staffed by qualified professionals with broad knowledge on treatment and service systems. It was suggested that this team operate a web-based and phone-based gateway service to provide cross-sector information and support to professionals and individuals seeking assistance with treating comorbidity.

An apparent lack of a consistent diagnostic tool for comorbidity, as well as a lack of consistent definition, was also identified. The report recommends collaboration between the Minister for Health and the Minister for Disabilities to develop and implement a shared diagnostic assessment tool, which will result in effective and improved client outcomes, increased interagency communication and cooperation, the use of consistent terminology in assessment referrals and the development of support plans, including accommodation options.

The increased interaction of people with a dual diagnosis or comorbidity with the justice system was something about which the committee received considerable evidence. It was suggested that people with mental health challenges are three to four times more prevalent in the prison population than the general community. Most notably, the committee heard very concerning evidence that there are a significant number of people who are incarcerated even though they have not been formally charged with any offence. This occurs based on their inability to formally plead due to some form of mental or cognitive impairment.

Members will probably recall from my previous contributions in this place that this issue is of significant concern to the Dignity for Disability party, so we were very pleased to have this issue brought further into the light. The report recommends that ministers collaborate to establish a process to formally collect data on people presently in the prison population who have not in fact been formally charged with an offence. I am hopeful that, if this data is collected, having a real idea of the scope of the problem will inspire some further action.

The report also recommends the need to identify the number of forensic clients with comorbidity who are in prison and, while in prison, are not receiving adequate supports around their health condition. The lack of appropriate accommodation options for people who are found not guilty by way of cognitive impairment, rather than a mental health issue, was also an issue brought up several times.

The committee heard evidence from people who were concerned about people with disability, such as an intellectual disability or an acquired brain injury, being accommodated alongside people with potentially quite significant mental health challenges and associated behaviours. The report recommends an investigation into the need for and the benefits and challenges of establishing a specific forensic facility for forensic clients with disability but no pre-existing mental health issue.

The committee also heard evidence regarding concerns about the fact that current forensic prisoners with no mental health issues, who are being housed in James Nash House, come under the care of the Minister for Mental Health rather than the Minister for Disabilities, by default. The report recommends that the parliament clarify, through legislative amendment, that such clients are to be the responsibility of the Minister for Disabilities and should only come under the responsibility of the Minister for Mental Health should they require support of a forensic nature separate to their disability at any time.

As I said, the treatment of people while they are in prison, especially those remaining in prison despite not having been found guilty of any offence, is of significant concern to Dignity for Disability, as it should be to all of us. Of course, there is also a need for us to focus on giving people with comorbidity the support to stay out of prison in the first place, particularly those who may be in a cycle of reoffending, which could occur for many reasons; for example, a lack of support in understanding difficult behaviour changes which may occur after an acquired brain injury.

To this end, I am pleased to see the report recommend increased mandatory training on issues surrounding comorbidity for relevant staff in areas such as health, mental health, disability, alcohol and other drugs—or, as I like to call it, 'drugs'—education and training, criminal justice, and homelessness, including the development of baseline course topics on understanding and responding to comorbidity.

I am not going to go into all the report's recommendations because they are detailed and numerous, but the last topic that the report covers which I will mention is the suggested need for more support for the people supporting people with comorbidity, particularly family carers as opposed to paid disability support workers; in particular, the need for increased access to respite to give family members a break from what is often the stressful role of caring for a loved one with what can be very complex needs. There is a particular focus on the need for emergency respite in situations in which there is what the report labels 'a behavioural incident'—and I do hope that that is not seen as too crude a term.

I think it is fair to say that at times there is often some level of division, between people with disability and family carers in terms of whose issues need to be addressed. That is, I suppose, the nature of things, the politics of disability, and every movement has its factions. My personal view—and I am sure that this will not come as any surprise—is that it is best to focus on supporting the person with disability, as the better they are supported the less strain there will be on the family carer to undertake to fill the support gaps.

However, I certainly acknowledge that while many people with disabilities do go without adequate support, this does place significant stress and demand on family members in particular. Coming from a party that was founded by a mixture of people with disabilities and family carers—most notably our current party president, Rick Neagle—as well as other allies, I certainly acknowledge the need to address both sectors.

We have certainly been very active on the need to give greater acknowledgement and support to family carers and people with disabilities over the years. I am sure members will recall us calling for an increased focus on the mental health of carers following a particularly tragic incident some years ago. Together with these measures, and more, and with collaboration and respect, we can build a better society for people with multiple diagnoses. I again thank the committee membership and the staff who have worked on this report and commend it to the chamber.

Motion carried.