Wednesday, 15 October 2008
Matters of Public Interest
Australian Defence Force: Mental Health Care
I rise today to speak on a topic that has been floating around in my mind for some years and which I have not had the opportunity to do the hard thinking on and bring to a conclusion. I have taken the opportunity in the last few weeks to give this particular topic some thought. I refer to the review of mental health care in the Australian Defence Force and the consequent transition as servicepeople move out of the forces and into civilian life.
At the outset I have to acknowledge that the Minister for Veterans’ Affairs, Mr Griffin, has announced that the review is to be conducted by Associate Professor David Dunt. That review, in my view, is very, very welcome and a very useful initiative by the new government. The review provides, for the first time, a comprehensive look at just one issue of defence personnel policy both during and after service. While the terms of reference for the review are quite wide-ranging, I would like to focus on two particular issues. The first goes to the governance arrangements between the Department of Defence and the Department of Veterans’ Affairs. The second concerns the current paradigm that applies to the application of military compensation assessments.
By way of background, since World War I we have seen the development of two separate but interlinked agencies. These agencies are the Department of Defence and the Department of Veterans’ Affairs. They are responsible for the care and delivery of services to the same group, the same cohort. The reasons for this, following two major world wars, are really quite obvious. The arrangements that exist today were dictated by the need after those wars to respond to the massive task of repatriation, compensation and health care.
Until 1999 there was a strict division between the services delivered to veterans by the DVA and the services delivered by Defence to serving and ex-serving personnel. However, today there are three major pieces of legislation that govern the healthcare entitlements of ADF personnel. They are the Veterans’ Entitlements Act, the VEA, administered by the DVA; the Military Compensation and Rehabilitation Scheme, the MCRS, administered previously by Defence and since 2004 by the DVA; and, from 2004, the Military Rehabilitation and Compensation Scheme, the MRCS.
The VEA is a scheme with its origins in World War I, and it changed little through World War II. It was eventually overtaken by more modern workers compensation legislation which had little, if any, regard for the unique conditions of warlike service. A decision to extend the VEA to peacetime service was made after the Vietnam War. This meant that at that time both the VEA and the MCRS operated in tandem. While a decision was made in 1984 to remove this duality, the legislation grandfathering the VEA and the MCRS and introducing a new single scheme for the future, the MRCS, was not passed until 2004. The DVA now administers claims under the MCRS as well as the VEA, bringing some consistency and simplification to service delivery. They were and remain quite valid aims.
The view seems to be that veterans’ matters should be separate from Defence and that this should be reflected institutionally. However, there are very critical linkages. The existence of two separate and longstanding agencies has been a problem with two departments covering the same client group in and after service. They draw from common services as well as separate programs. The model therefore has a number of inefficiencies in terms of service delivery. The key difficulty remains that health and welfare problems addressed by DVA have their causation during ADF employment; however, the costs of compensation programs are not attributable to Defence. The shift in responsibility for MCRS and associated rehabilitation and treatment now accentuates that gap. The outsourcing of military compensation and rehabilitation to DVA in effect allowed, and continues to allow, Defence to shed its responsibilities. The issues surrounding mental health care should be seen in this light of the ongoing division of responsibility. There is a legitimate concern about lack of continuity and the need for consistency in the application of medical science. It should also be mentioned that Defence, as the employer, has an obligation for occupational health and safety—a responsibility to be accountable for the outcomes and cost attribution, which is not possible under the current model.
Mental health care is an area where there have been consistently unsatisfactory outcomes. The disconnect between DVA and Defence can be very clearly seen in the area of mental health care. The transfer of serious problems which emanate from ADF service were also a feature of the inquiry into military justice by the Senate Standing Committee on Foreign Affairs, Defence and Trade. In submissions, some discharges from service could be linked to bullying and harassment that resulted over time in mental health outcomes. In more extreme cases, treatment of individuals resulted in suicide. Whilst not everyone is suited to defence service, some find themselves in circumstances that are very stressful. It must be said that in the past there is evidence such problems have not been well managed. Individuals or family members of those discharged in this way spoke of a lack of support and care beyond that provided by ex-service organisations and community care. The point I wish to make is that this current system has had an adverse impact on the continuity of care. The preference should always be, in my view, for a holistic model regardless of the boundaries in institutional arrangements. It is unfortunate this approach has not been taken to date.
In a recent report by Mr McLeod into the suicide of Signaller Gregg it was noted that a third agency, ComSuper, was also now involved. His recommendation was that ComSuper’s responsibility for assessing incapacity be passed to DVA, and it is a very valid recommendation as it might remove one player from the game. In this context, it is worth noting a recommendation of the review into military superannuation: that death and disability payments cease being paid as a superannuation payment. This will eliminate the need for ComSuper to be part of the process. It is a significant change and one quite worthy of very thorough investigation into the future. It may be more appropriate that disability assessment be included in the MRCS Act regardless of the administrative body charged with delivery of programs. However, the relative suitability of the current ComSuper in the MRCS regimes would need to be carefully assessed. We need to ensure that the assessment of permanent or temporary disability—physical or mental—be consistent, rigorous and independent. It should be based on best practice and current medical science if available. Ultimately the aim should be for rehabilitation but the compensation framework has changed little since World War I, particularly in the area of mental health.
While the debate on changes in respect of shell shock, battle fatigue and now PTSD reflects a growing sophistication and understanding of mental health issues in the services, it has been suggested that the compensation scheme has been counterproductive and may well exacerbate the problem in a whole range of areas. In short, the compensation scheme as it is currently designed is only suitable for measurable loss after physical rehabilitation. For mental health disabilities this may not be the most appropriate model. By their nature they may have a late onset, they may fluctuate according to intervening and extraneous circumstances and they may be attributable to service more because of the application of the relevant act than any because of any other single factor.
The other difficulty is that compensation should be available only after a condition has been realised. This presupposes early onset, early diagnosis, treatment and rehabilitation to a stage where permanence can be assessed. With psychological disorders this may not be possible. Many service personnel experience a delay in diagnosis and treatment to a stage when intervention is not always successful. People are discharged with an undiagnosed psychological disorder and effectively bypass the DVA system. They remain undetected and untreated because the compensation system has not been triggered. Early self-awareness prompting presentation, diagnosis and early intervention cannot be relied upon.
The early response to mental health issues for returned servicemen from World War I was the creation of the ‘burnt-out diggers’ pension. It was effectively the age pension made available to those so affected by their war service that they were unable to work. These were the men who could not settle down, who humped their bluey or who became reclusives living on the fringe—and these still apply in all states to veterans of the Vietnam conflict. There was no treatment except institutionalisation, and that benefit is still available. It is provided to those deemed unable to work but who are under the service pension age of 60 years and who have been accepted as qualifying for payment of a particular benefit. It is unclear whether those accepted as being permanently of this condition seek further treatment. The statistics on that critical matter are simply not available, and I believe this is a critical failure within the system itself.
The predominant policy and legal requirement is that of the benefit of the doubt. It was first given after the horrors of World War I in an era of inferior medical science. It continued through World War II, and is confirmed now in the statements of principle that apply in this area. As we know, with physical injuries there is a health record that everyone can rely on. But, with mental disorders, cause and effect is much more doubtful, much more problematic. The question therefore is whether the current regime is appropriate and whether an alternative model might be considered. Whether notification of mental illness is treated before compensation becomes the predominant issue. This approach would provide temporary income support until such time as rehabilitation has been attempted. It would provide a longer assessment period for stabilisation. Currently, there is a period of 45 weeks on full pay in the ADF pending rehabilitation, redeployment and discharge. This may be far too short for non-physical disabilities. The importance of redeployment and retraining in lieu of medical discharge is, of course, consistent with modern compensation policy. However, the rules governing compensation in this area have prevailed far too long. There is also, of course, the stigma attached to mental health problems in the ADF. As a result, there is little incentive for personnel to seek treatment. If compensation were removed as an early option, there might be a requirement for a more rigorous treatment and rehabilitation regime.
The stresses of serving in our defence forces are a very real issue, and they are often overlooked, given the necessary focus on physical injury and combat death. The transition from service to civilian employment and family life should be as smooth as possible. Service men and women requiring special postdeployment support and care should receive it. The issue of governance has led to confusion in policy responsibilities for military compensation between the two lead agencies of Defence and the Department of Veterans’ Affairs. Program delivery can be delegated to DVA, but occupational health and safety should and will remain the moral responsibility of the employer—the Department of Defence. (Time expired)