Fixing the NDIS won’t help the one in five Australians living with these challenges

Australia has two crises in social policy. However, they are different. The highly visible, much-discussed NDIS spends too much and applies to too many people, according to the government. Since Wednesday, there has been a commitment and a strategy to fix it.

The less visible, less-discussed mental health system is the opposite: it spends too little and applies to too few people who need care and support. And it lacks a commitment and strategy for reform.

The mental health challenge is very big. More than 800,000 Australians have a severe mental illness, mostly of psychotic forms (e.g. schizophrenia, bipolar). Every year, one in five Australians between 16 and 85 years old experiences a mental health challenge requiring care and support.

One failure concerns the “missing middle”. At one end, there’s a system for dealing with primary mental health problems. It mostly involves GPs and psychologists. It is imperfect and inadequate. Nevertheless, the system does exist.

At the other end, there is a system for dealing with people in severe distress, including those experiencing psychotic outbreaks. It is hospital care. That system has even more imperfections. These days, overstretched hospitals only consider accepting someone when they are in acute crisis.

In between lies a vast and largely unserved population of people with moderate to severe mental illness with complex needs, involving people with anxiety neurosis, chronic deep depression, borderline personality disorder, eating disorders and many other afflictions.

All this is in addition to the many people with psychotic forms of mental illness who do not get hospital treatment. This challenge is made no easier by the Commonwealth/state division of responsibilities in this field.

The problems are visible in the data. People with schizophrenia, for example, live on average 20 years less than the general population. Suicide rates remain very high. People with mental illness make up a very significant part of Australia’s disadvantaged population, disproportionately experiencing homelessness, low-standard, dangerous and insecure housing, imprisonment and social and economic isolation. Mental illness makes up about 15 per cent of the burden of disease in Australia, but it only attracts about seven per cent of national health spending.

The problems are also clear in countless individual stories and tragedies, for example, as shown in the coroner’s report on the Bondi Junction shopping centre killings.

“Psychosocial disability” is frequently associated with severe mental illness. It involves substantial ongoing impairment and confusion in managing daily living tasks such as self-care, obtaining healthcare, social relationships and participation, housing, finance, employment, etc.

My own daughter, Isabella, has life-long schizophrenia, with associated major difficulties and confusion in her daily life.

A good development is that Health Minister Mark Butler has affirmed that severe psychosocial disability should be in the NDIS. Nearly all those in it at present have serious mental illness and associated serious disability.

Interestingly, he has observed that people with psychosocial disability may be underrepresented in this scheme. The NDIS approach to psychosocial disability itself needs reform.

It has been driven by an inappropriate physical and intellectual disability approach. The NDIS review of 2023 recognised this shortcoming and laid out a pathway to reform that needs to be acted on. Although the reforms within the NDIS are important, the reforms needed for mental health generally dwarf them in magnitude.

First, so-called foundational supports for people with psychosocial disability must be established in the same way, and with the same or significantly greater support, as for the Thriving Kids program for children with autism and development delay.

Second, government-commissioned analysis shows that 647,300 people with moderate to severe mental illness require both mental health and psychosocial support. Combined, the NDIS, state programs and Commonwealth initiatives meet just 24 per cent of that demand. Seventy-six per cent (493,000) people have unmet needs.

Third, a few years back the Commonwealth, state and territory governments announced the National Mental Health and Suicide Prevention Agreement and claimed it would change mental health. Those of us in the mental health community didn’t believe it. The Productivity Commission’s recent review found we were right.

Systems remain uncoordinated, unfunded, unaffordable and difficult to navigate. Key commitments have gone undelivered. The older agreement has now been extended to June 2027; governments are aiming to land a new one this year.

The question is as it has been for two decades or more – whether this time would be different.

Strangely, in general discussions about productivity, no reference is made to the Productivity Commission’s 2020 Mental Health Inquiry Report, which concluded that mental ill-health and suicide cost the Australian economy approximately $200 to $220 billion every year, and that very substantial gains in productivity and GDP would occur if there was greater investment in mental health.

These include reductions in deaths, better health, lower health and social services costs, higher workforce participation by persons with mild and moderate mental illness (and by carers), better on-the-job productivity, less absenteeism and the reduction of social and economic isolation of people with mental health challenges.

To solve these problems, we require a commitment to investment and an integrated co-ordinated approach driven by a taskforce that brings together people with an informed understanding of what works and what doesn’t work in mental health care and disability.

In short, mental health reform is required, but in a different manner from NDIS reform. The public can be assured there never has been, and never will be, overspending on mental health. But a greater commitment is needed.

Allan Fels is chair of Mind Australia, and former chair of the Australian National Mental Health Commission and the Australian Competition and Consumer Commission.

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