Tag Archive for: mental health

Defence medical services need more prevention, faster return to work

The imminent royal commission report into Defence and veteran suicide will probably be quite scathing of the Department of Veterans’ Affairs and the Australian Defence Force. But the report, due to be handed down on 9 September, will probably overlook two root causes of military mental illness: the great volume of preventable work-related sickness and injury among ADF members, and the ADF’s reliance on contract civilian health staff.

Civilians who are treating sick and injured ADF members are poorly placed to promote recovery and mental health with one of the most important treatments: getting people back to work as soon as possible.

These causes reflect a longstanding, widespread yet never-tested premise that ADF members need only short-term clinical treatment and that the only reason the ADF needs uniformed health personnel is because civilians cannot deploy. This premise formed the basis of a 1996 Australian National Audit Office (ANAO) audit that found that the ADF’s per-person health costs were three times as high as for civilians treated through Medicare. The audit blamed gold-plated health services, with the result that the 1997 Defence Efficiency Review contracted out those on ADF bases.

However, the ANAO’s cost comparison was invalid, because the ADF and Medicare systems have different scopes of care. The main reason for the high cost of ADF (and the Department of Veterans’ Affairs) health services actually relates to the volume of preventable work-related illness and injury.

Although inconsistent, state and territory data suggests that an ADF member may be 12 times more likely to claim compensation for work-related injury as an average civilian and five times more likely than a manual labourer (who on average would suffer more injuries than anyone).

Furthermore, a 2016 study found that up to 90 percent of all Australian Army work-related injuries were not being reported, which suggests that the problem is even worse than this compensation data indicates. We can assume that navy and air force underreporting would be similar.

To use the metaphor in an 1895 poem by Joseph Malins, rather than ‘a fence ’round the edge of the cliff’ to stop people from falling, the ADF has instead put ‘an ambulance down in the valley’: we’re focused far more on treating avoidable harm than preventing it.

This error is compounded by the unfair expectations placed on the ADF’s contract civilian staff in assessing fitness for work. The fraction of navy personnel who were medically unfit for sea rose from 4.8 percent in 1996 to 13.8 percent in 2018, while those with at least one medical employment restriction rose from 9.4 percent to 40.2 percent in the same period. This increase is typically ascribed to lower recruitment medical standards.

But another explanation is that the ADF now employs civilian doctors who lack experience in dealing with work-related injuries, compared to doctors whose military experiences give them a better understanding of the demands of ADF employment.

And absence from work is itself a psychological as well as a medical problem. As the Royal Australasian College of Physicians has explained, it leads to avoidable mental health issues, because:

—Absence from work leads to poorer health;

—Resting while waiting for recovery actually delays recovery;

—The longer people are off work, the less likely they will ever return to work;

—Most common health conditions are not cured with clinical treatment alone; and

—Useful work is itself a therapeutic intervention and therefore part of the treatment.

There are at least three possible reasons why we’re not getting injured and sick people back to work as fast as we should. One is that contract health staff lack the ADF workplace experience that uniformed health medical people can use in judging what work a patient can and can’t do.

Also, contract health staff tend to take a stronger, possibly misapplied, approach patient advocacy, often by recommending more time off work than needed.

Finally, no doctor can get a patient back to work if veterans groups, with commendable intentions but often regrettable results, are meanwhile ensuring that patients know how to maximise the compensation benefits to which they are legally entitled. Compensation payments for ADF members appear to be about twice as high as those for civilians.

Arthur Graham Butler, a Gallipoli veteran and author of the official Australian medical history of World War I, explained that military health services have two purposes beyond immediate casualty treatment: facilitating the operations of their patients’ commanders, and helping the injured and sick eventually to return to civilian life. Both mean getting as many service personnel back to gainful work as soon as possible.

But the current ADF health services are designed only to provide treatment.

The commission ought to recommend greater emphasis on prevention of injury and illness and, for those who do need medical services, hastening their recovery by returning them to their ADF duties or civilian employment as soon as possible.

We’ll take a big step towards achieving that if we recruit more uniformed medical staff.

Helping Australia’s first responders deal with the trauma they see daily

Australian first responders dealing with fires, crimes, crashes and pandemics are in danger of being overwhelmed emotionally and they are three times more likely than other Australians to consider suicide.

That statistic has long worried former Victoria Police chief commissioner Graham Ashton, who will be announced tomorrow as chairman of Fortem Australia, a not-for-profit organisation providing mental health support to members of first responder agencies and their families.

Agencies include state and territory paid and volunteer emergency services, such as fire and rescue, police, ambulance, and rural and community-based firefighting services, along with national organisations such as the Australian Border Force and the Australian Federal Police.

Ashton headed Victoria Police from 2015 to 2020 after a long career in the AFP.

During his 40 years in law enforcement, Ashton developed a strong concern about the need to address mental health issues in policing. He ordered a major review of the adequacy of mental health and wellbeing services in Victoria Police, which was followed by a series of reforms within the police and the start of efforts to improve support for police veterans.

Ashton retired on 1 July and was asked to join Fortem to use his experience to help develop and expand services for a broader range of first responders and their families.

Fortem, which means ‘strong’ in Latin, was established by John Bale, co-founder of the Soldier On mental health support group for defence personnel. ‘Graham was instrumental in leading mental health reform with Victoria Police and brings to Fortem this understanding of how vital connection and support are for wellbeing and mental fitness’, Bale says.

For a time, Soldier On broadened its orbit to take in first responders confronting mental health issues but found that those issues and the levels of support already available were significantly different.

‘Defence is a massive organisation’, says Ashton. ‘What will emerge from the work of Fortem is that the issues in the first responder area are so significant that they need their own focus, not just to be part of, or pinned to, Defence.’

He says the whole concept of mental health and other support for law enforcement personnel and other first responders is not as mature as it is in the military sector.

Ashton says that everyone in the community will at some stage have issues with mental health, major physical health issues, death of loved ones or workplace issues.

‘First responders are living their lives like everyone else, but on top of that they are working in a stressful environment where their safety can be at risk and where they are often dealing with very traumatic things. That amplifies the operating environment they’re in beyond that which we all have to deal with on a daily basis.

‘It’s an area that has needed attention for decades and it’s very pleasing that Fortem exists with a dedicated focus to address these issues. Fortem has come along at the right time and I think it can make a big impact.’

Bale says that every day, more than 300,000 first responders are at work keeping communities safe. They are backed up by their families—partners, children and parents. All of them hold vital, challenging roles. ‘We help them to be well, and stay well, through mental fitness support services and wellbeing activities.’

Fortem connects with first responder communities to have a positive impact on their overall wellbeing. ‘We support first responder families to improve and protect their mental fitness, we  connect families to strengthen family bonds, we activate community and individual awareness and education, we collaborate with organisations to foster a collective effort to improve wellbeing, and we deliver evidence-informed, community-based health and wellbeing support programs specifically designed to address the unique challenges faced by the first responder community.’

These programs are delivered virtually as well as in person. A team of psychologists works in person, by phone and online to help first responder families, assessing and triaging needs. The specialists also run group programs on mental fitness designed for first responder families.

Ashton says a significant first step for Fortem is to provide independent clinical support to agencies and the workers within those agencies. ‘Sometimes there is not the trust between the employee and the employer in relation to mental health so that they’ll seek support or treatment. But they may be attracted to an independent agency.’

Another vital role for Fortem is in raising awareness and acceptance of mental ill-health.

‘In the first responder world, the culture has long been that you are the person who is expected to cope. So when things become difficult, you are not culturally encouraged to speak up.’

Ashton says that in the first responder community, that stigma is alive and well.

‘It’s a stigma in terms of their workmates, in the workplace. It’s a stigma in the community, and some of them think it’s a stigma within their family as well.’

‘Fortem can work on its own and also with other organisations to address that stigma issue in our sector so that we can get people more willing to seek support earlier for difficulties they may be encountering.’

Police work can be extremely stressful, as is working in fire or ambulance or in rescue services, says Ashton. ‘You’re often dealing with people at the most vulnerable time in their lives. You are trying to bring some sense of normality and order and progress to the issue that they are suddenly trying to deal with.’

Someone involved in a car accident resulting in death or injury will remember that for the rest of their life, he says.

A police officer attends that event and then they go to the next one, and the next one. They do that as a matter of course, but it can have a cumulative effect. The stress builds up and it can be challenging in terms of maintaining good mental health.

‘My own experience is of having been a first responder and then being in charge of first responders as a senior police officer, and also in having some lived experience in relation to good mental health’, Ashton says.

‘I suffered a period of burnout in 2017 and I was very public about that. I’ve got lived experience. I’ve been managed and I’ve taken a strong interest in managing and leading employees who had difficult times in their own mental health and more broadly for members of families.’

Fortem’s initial focus has been helping the recovery of personnel and families from the Black Summer bushfires.

‘It’s good that Fortem has both a clinical and a wellbeing focus’, says Ashton. ‘It’s able to provide on-the-ground clinical support, which is locals helping locals, and it’s very much also about ensuring that it can look after wellbeing and do the proactive work as part of that.

‘As a new agency, we’ll also learn a lot from this work that we’ll be able to apply in the years to come.’

The case for a royal commission into veteran suicide

In recent months, Australia’s veterans and their brave family members have been calling, ever more loudly, for a royal commission into veteran suicide.

The need for a royal commission is real. It is urgent. And it should be absolutely bipartisan, because this is not a political exercise. This is a national crisis. The veteran death toll by suicide since 2001—by the most conservative of measures—is 10 times greater than our losses in Afghanistan. These preventable deaths of our service men and women must stop.

Calls for a royal commission have been led by people like Julie-Ann Finney, who shared her son’s heart-wrenching story with parliamentarians last month. Such tragically common stories have inspired a national movement supported by over 268,000 Australians and the Daily Telegraph’s #SaveOurHeroes campaign. While no one can speak for all 641,000 Australian veterans, this represents a significant demand for answers and action from our community.

Like far too many veterans in Australia, I’ve lost close mates to suicide and know others who have attempted suicide during the struggle of transitioning from service to civilian life. I consider a royal commission into veteran suicide an urgent moral imperative, not least because nothing else has worked.

The prime minister alone has the powers to call it. He recently told parliament he would actively consider calling a royal commission over the summer break and decide in the new year.

Of course, a diversity of views exist on this question, including among veterans. And there is no overarching peak body that can claim to speak on behalf of the more than 6,000 ex-service organisations, whose own leaders do not always reflect the views of their members.

Some people object that royal commissions are a waste of money and achieve little. Government sources have even floated that the flagged $100 million cost of a royal commission might be better spent funding core Department of Veterans’ Affairs programs.

But royal commissions can be catalytic and even nation-defining. And they are not to blame for any lack of political will to implement and fund their recommendations. Their job is to inquire, not to govern.

As for the claim that there’s a trade-off between delivering core services to veterans and investigating the suicide crisis, this is akin to saying that we can’t tackle two policy challenges at once.

Reforms that are underway now can continue during the royal commission process and, if done right, will result in better outcomes than the current ad hoc approach to veterans’ services. DVA’s services are considered generous by international standards, but the rising veteran suicide rate shows that funding isn’t the main issue here.

Another common critique is that a royal commission should not be called before all prior recommendations have been implemented in full.

This objection is misleading. The Productivity Commission report released in July had a much broader mandate and produced only four recommendations on veteran suicide. Three of those were about DVA better advertising and reporting on its work. The fourth called for the Department of Defence and DVA to urgently develop a strategy. To my knowledge, none currently exists.

Meanwhile, DVA has responded to or is implementing all 24 of the 2017 Senate inquiry’s recommendations, yet suicides are not slowing. If we face systemwide institutional failure, a royal commission is precisely what is required to determine why interventions are failing and to set a new course.

A small number of vocal ex-service organisations opposing a royal commission have claimed that veteran suicide is inseparable from the general suicide rate.

This is frankly absurd. Every dataset we have consistently confirms that the veteran suicide rate is very different to that of civilians: it is often lower for serving members and spikes dramatically on discharge, with women veterans’ suicides also higher than the civilian rate. By all accounts, veteran suicide rates are sociologically distinct. To deny this is to turn our back on our service men and women.

Prime Minister Scott Morrison will no doubt have a lot on his mind over the break, including dealing with the devastating bushfires across our fire-ravaged country. But I call on him to give hope to those veterans and their families who may be struggling this Christmas.

The veteran suicide crisis calls for urgent action and Labor stands ready to support the prime minister in taking it.

Policing on the front line of mental health emergencies: mind the gap

The issue of mental health is one that police across Australia have become all too familiar with. The deinstitutionalisation and movement into the community of people with severe mental illness have resulted in the police becoming the default front line in managing such people during crises. Mental health calls often involve medical emergencies rather than crimes and don’t require a police presence except to facilitate access to medical care. The brutal reality is that the police haven’t been provided with the right tools for such interventions and their response is often inadequate.

People often ask whether the police are properly trained to manage such calls: do they have the appropriate mechanisms, capability and capacity to deal with the mentally ill? That’s the wrong question. The question should be, ‘Why are we sending the police to mental health calls without access to the tools they need?’

Of course, attending to mental health crises and people battling mental illness, searching for people who have walked away from care and trying to connect the mentally ill with the services they need are all part of the role of today’s police officer. The problem is that once police respond to such calls their access to onsite or even post-call care is limited.

The Royal Australian College of General Practitioners annual report for 2017–18 identified mental health problems, such as depression, mood disorders and anxiety, as the most common issues brought to GPs. That doesn’t surprise most police officers—they see these problems every day in all jurisdictions. In the ACT, the Australian Federal Police found that a full 10% of callouts were of this type. That result was in line with the findings of other studies, including one published in Psychiatric Services in 2016, which showed that one in four people in Canada, the US and the UK who had mental health episodes had been involved with the police.

The challenge for police is that there’s a disconnect between their training and what they’re expected to do. Most police training in mental health is focused on managing situations, particularly those in which people may become violent or dangerous, but the reality is that the mentally ill require an intervention, more often than not by a mental health specialist.

The NSW Police Force has been running a special program—the Mental Health Intervention Team—for more than a decade that focuses on reducing the risk of injury to police and civilians; improving police officers’ awareness of mental health issues; increasing collaboration between the police and responsible agencies; and reducing the time between frontline and medical interventions. This closely mirrors other programs in Australia and abroad and is seen as a success. The problem is that it isn’t enough.

The police can’t say no to mental health callouts; they have a legal responsibility to respond. The question is twofold: Are they trained to the level required? And do they have the necessary access to mental health professionals? There are no other medical emergencies in which we expect the police to be the first and often the only line of defence.

In my discussions with police in some jurisdictions, I was advised that mental health callouts make up more than 20% of all calls for service. That, coupled with the fact that it can take many hours to get the person into the hands of a mental health professional, means it’s common for a police officer to begin and end their shift managing just one case.

What we need to focus on now is ‘minding the gap’. The police are clear that they must have rapid onsite aid from mental health professionals when needed. Mental health professionals might not feel safe in managing some calls without the aid of police officers. The emergency systems, both health and police, must work hand in glove if they want to manage these calls appropriately, effectively and efficiently.

Any strategy must cover police training, how the police are engaged and how they’re supported to bridge the divide between the demands of the community and their ability to meet those demands. Minding the gap will only be accomplished by having a coordinated response using both the police and mental health professionals in the community on the front line as an immediate response.