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Standing Committee on Family and Community Affairs - 17/08/98 - Indigenous health

CHAIR —Welcome. This committee does not formally swear its witnesses, but you need to know that the proceedings today are legal proceedings of the parliament and warrant the same respect as proceedings of the House of Representatives itself. Any deliberate misleading is therefore considered as a contempt of the parliament. It is a process that provides protection for witnesses so that you can be fearless in what you tell us today.

The committee has not had a submission from your medical service but has received one through the Aboriginal Medical Services Alliance. We are pleased that you have been willing to come and talk to us to add to that submission from your own perspective. I will give you an opportunity for a brief statement to make your points, and then we will proceed to questions from my colleagues.

Mr Robinson —I think one of the first things that we would like to talk about is, basically, what is Aboriginal community control. That is very much an aspect of the AMSANT submission that you already have. It is also very much an aspect of the Congress Aboriginal Medical Service submission that they made, I believe, in October when you were in Alice Springs.

You will have heard from Territory Health Services, and you asked questions regarding community control. We have a slightly different perspective on what we believe is community control. Firstly, community control arises from the community itself. Is it a community initiative? To us, this is probably the most important ingredient. Community control should not be imposed by governments for whatever reason. It has to arise from the community.

Secondly, the community elects a committee to worry for the organisation. Their role is the philosophy, direction, policies and vision of the organisation. It is not the role of the committee to participate, interfere or direct the day- to- day running of the organisation.

Thirdly, the committee of an Aboriginal community controlled service employs a senior staff officer. In the case of Danila Dilba, this is the director of the medical service. Our director is Pat Anderson, and she is currently in Alice Springs with another committee which, I think, is the MBS and PBS. I give her apologies for not being here today. The director is directly answerable to the committee and, in turn, the community. In effect, the

director has many, many bosses in the community. The committee hires the director, and it is our philosophy at Danila Dilba that at all times the director of the medical service must be an Aboriginal person. The director is responsible for hiring, firing, management and all aspects of the service.

The fourth aspect of what we believe a community controlled organisation is is that it is an incorporated organisation. In our case, it is incorporated solely to worry for health. It can be incorporated under the Aboriginal Councils and Associations Act, it could be under Australian company law or under the Local Associations Act here in the Northern Territory, but it must be incorporated and should be solely to worry for health. There must be a register of members, and at annual general meetings it is only the members who should be allowed to vote.

The fifth characteristic of what we believe a community controlled organisation is is that it should operate at all times within the budget, whatever that may be. Sixth, community organisations must be totally transparent—that is, open for all to see. An annual report and an annual general meeting are essential. This is where the organisation reports directly to the community about the progress of the organisation, the difficulties, future directions, the wins and the losses. As well as that, we submit audited accounts for the public record.

As I said before, the directors have many bosses—the community. Our service at Danila Dilba is very public. We are in the eye all the time. If we do something wrong, we will hear about it. An important part of our work, and an important aspect of the community controlled organisation, is the politicisation of our work. Health cannot be separated from land rights; it cannot be separated from education; it cannot be separated from employment. They all go hand in hand.

Community control is self-determination in practice: communities making their own decisions about their own health. We have taken the mainstream model and adjusted it to suit the needs of the community and, in our case, the Danila Dilba way of operation.

Lastly, we believe that an Aboriginal community controlled service must accept that close enough is not good enough. The community deserves the best, and it is a cop-out to say that there is an Aboriginal way of doing things, Aboriginal timekeeping. This is something we do not accept at Danila Dilba. We must provide a quality of service to our clients. Anything less than that is a cop-out. The community demands that what we do is the very best of whatever we can do. This is true for all community controlled organisations, be they education, legal, housing, land councils, et cetera.

Basically, to sum up, we believe that a community controlled organisation must be directly elected by the community, that it must arise from a need expressed by the community, that it must be controlled by the community and must, of course, be responsible to that community.

CHAIR —How is it initiated, though? You are saying that the community has to decide it wants to do it, but it needs to be stimulated enough for them to have that debate and discussion, though, doesn't it? It is a partnership in getting it started, don't you think?

Mr Robinson —We started because there was a need in the community. There had been several attempts to create a medical service, but I think one of the problems we had was that it was quarantined because it was inside Bagot, which is an Aboriginal reserve in the centre of town here. I think people felt they were restricted because of the ownership factor of being inside Bagot. Since we have moved to McLachlan Street, and then subsequently up to Knuckey Street, the membership has increased. I think we are up to 500 members now, and that is in a period of about four or five years. So that membership has indicated the community's involvement in the service.

Mr QUICK —What sort of responsibilities does the community have? It is okay to say, `Look, here are your rights and you want to go and set up your own medical centre.' The other side of the coin is that there should be some responsibilities. So what responsibilities are there amongst many of your members to say, `Look, okay, we understand that there are certain behavioural matters which will affect our long-term health outcomes'? Do members then say they are going to willingly participate within some of the medical programs that you are going to operate as a community? Are there those sorts of rights and responsibilities, or is it all rights and no responsibilities? What sort of best practice are you trying to encourage within the community to say, `Okay, if we can convince the bureaucrats of the Commonwealth and state to give us that autonomy, we will be part of a process with some long-term beneficial outcomes'?

Mr Robinson —I think that is a very valid point. When you apply to become a member of Danila Dilba, you are asked whether or not you wish to be a volunteer of the organisation. The vast majority of people who make application to be members do tick that box. We use the volunteers and actively solicit their involvement in getting that health education message in particular across to the community. That has been evidenced recently by the participation of community members in our stall at the Royal Darwin Show. It is evidenced in our other big event that we have each year—AIDS awareness week—where members of the community, not just members of the committee, put their names down to participate in these workshops and education sessions.

In addition to that, there are several programs we have established that we call advisory reference groups. Members of the community with a particular interest in a particular issue—it may be emotional and social wellbeing, it may be women's health, it may be sexual health—can participate in setting the formulation of policy and practices and programs in that area. I think that has been accepted by the management committee as an excellent way to involve the community and, yes, to get members of the community to exercise some responsibility. It is no good just bitching about things not being done without putting your hand up. It is rather like being in politics.


Mr QUICK —If there is, for example, substance abuse and petrol sniffing, and if you are a member of the community, you are willing to participate in preventative processes; is that the next step? Where are you in that sort of process?

Mr Robinson —In the area of substance abuse, particularly in Darwin, most of our work is of a referral nature from the other agencies who work in this area. There are other community control agencies such as the Foundation of Rehabilitation of Aboriginal Alcohol Related Diseases—FRAARD—or the CAAPS program. We provide the clinical-medical side of the programs that are run by both of those agencies.

We do not see very much petrol sniffing at Danila Dilba. It seems to be more down in the Centre, although there are anecdotal reports of it being in some of the island communities. Our direct involvement in some of those program areas is negligible—more in the way of clinical advice to the other agencies.

Mr QUICK —We took evidence in South Australia where the community has taken over responsibility for alcoholism. Rather than the police going around and picking up people, they have their own van in which they go around. There is a community responsibility to remove them from the potentially dangerous situation, as far as custody goes, and then bring them into some sort of detox unit. Do you have something along those lines within your community?

Mr Ah Mat —We are a little different because of the nature of the place. In some communities, like Tennant Creek, where they have got the night patrol, they have their own people looking after their own people. Because of the diversity of Darwin, we have not got the same luxury of having our own resources to look after our own mob. The night patrol has just started here.

Mr QUICK —How do the various communities within Darwin get together, instead of having 14 vans wandering around trying to identify each individual community's responsibility? How do you put in place an overarching strategy to deal with that sort of situation?

Mr Ah Mat —We, from memory, supported the AMS submission that went to the government here—that they be the organisation that manages that program. I am not aware of how they have done that. I think they have advertised the positions and people have applied. There were some concerns that, because it is only in its infancy, it needs to be tested as to whether it is an effective way of dealing with the alcohol problem in the town. This program has been operating for less than six months. We were concerned that it had to be on the basis of groups looking after themselves and, because people from the Centre and from west of here come into this town, we would need a whole lot of resources for people to look after their own mob.

Mr Robinson —We did a snapshot a couple of years ago of people who used

Danila Dilba and where they came from. It showed that 41 per cent of all of our clients over a three-week period actually came from Darwin. The remainder were visitors passing through. It is important to remember that Darwin is a hub centre. We get the east Arnhem coming through, we get the Tiwi coming through, we get the Kimberley mob ending up this way, and the Katherine mob come up. A lot of it depends on the sporting events at the time. Trish Angus mentioned the Tiwi football final. Usually, there is a big influx of people going through. In addition, we get people coming to Darwin for specific medical problems—men's business or women's business—because of problems talking about that or a lack of resources in their own community.

Mr Ah Mat —Our contact with the community where these people come from in terms of us looking after their health indicates our community approach to dealing with the matters. I think we can be linked up to a computer system to contain records, et cetera. That is another way in which we are influenced by what the community is saying about particular patients and their needs.

Mr QUICK —Are you the only Aboriginal medical service in Darwin?

Mr Robinson —We believe we are the only Aboriginal medical service in Darwin. There are facilities provided in the Bagot community by the Bagot Council. The direction of that is by the community council and they do not specifically wave for help.

Mr QUICK —How do you liaise with the various communities? You mentioned that 60 per cent came from other communities. They all get their own bag of money and you get your bag of money. How do you dip into theirs and say, `In any given period, we are going to be dealing with some of the people from your community'? How do you then prioritise strategies to say, `We need extra money to provide dental services because we realise we can't cope because of our own budget constraints'?

Mr Robinson —This has been an issue for some time. It is one that we have talked about, particularly at AMSANT meetings—the Aboriginal Medical Services Alliance of the Northern Territory. Unfortunately, most of the people who come through our doors are from areas that are not covered by AMSANT members. Yes, there has to be some facility so that this can happen. It is a question that was raised with the Tiwi coordinated care trials. What happens if a person who is on the trial comes through Danila Dilba? That is a question that we really have not resolved. It has not happened yet, but it may happen in the future.

We talk to those other communities, but those other communities are quite often strapped for cash as well. I think it is probably fair to say it is pretty much a one-way street. Most of the community members come to Darwin, not the other way around. Yes, it is of concern and we have talked about it. We have brought it up in the rebasing exercise that was undertaken by the Office for Aboriginal and Torres Strait Islander Health Services some years ago. We had hoped that these types of factors would have some

bearing on the money that we get to run the service, but it has not. With the funding that we get, there is no mechanism as far as I can see to allow for these people coming from other communities. We are not suggesting that a bill should be sent off to the Tiwi Islands once a month or whatever, but there has to be recognition that we do service more than just the Aboriginal and Torres Strait Islander population of the Darwin area.

Mr QUICK —What would your solution be regarding the educational opportunities and training of Aboriginal medical workers? Is there a solution or are the educational opportunities so small that we are never going to resolve it?

Mr Robinson —Danila Dilba is a registered training provider and we run an accredited course for the training of Aboriginal health workers.

Mr QUICK —Just in Darwin?

Mr Robinson —We just do the Darwin area at the moment. Last year we had over 100 expressions of interest—people wanting information. I think we ended up with 52 applications and in the end we accepted 15 people into the course.

Mr QUICK —Why was that?

Mr Robinson —We are only funded for 10 and that is the basic factor in it. There is a crying need for trained Aboriginal health workers.

Mr ALLAN MORRIS —Who funds that?

Mr Robinson —That is funded by the Northern Territory Employment and Training Authority, NTETA.

Mr ALLAN MORRIS —Through DEETYA?

Mr Robinson —ANTA, I think it is. They give us $98,000 a year. That seems to be non-negotiable and non-changeable. Already, the clinic supports that training effort to the tune of something like $10,000 a year. We run a very basic service. It is pretty well no-frills in the training area and any extra money we get would improve the numbers of people we can put through. That has been a priority identified by the committee. Last year they wanted to see the numbers that we could put through double but the funding just is not there to do that at the moment.

Out of those health workers that we have been training, we have had two graduations, I think. The third class is going through this year. To the best of my knowledge, the health workers that we have put through have found employment. We are employing three or four of them at the clinic at the moment. They are working at the Royal Darwin Hospital. They are working in the various island communities. All reports

coming back are that their training and expertise is excellent and quite exceptional.

Mr QUICK —Where do they go after they receive their basic training? Is there a series of steps that they can progress through?

Mr Robinson —They leave us with an ASF3 certificate. That will allow them to move on to an associate diploma and then on to a diploma.

One of the features of our course is that we have a high clinical competency component, and I think this is borne out in the quality of the graduates. We would like to offer these higher courses, and we have permission to offer them, but the big problem, of course, is the resourcing of that. When you come to visit us, as I believe you will on Wednesday, we will show you our training facilities. We seem to be well resourced in the form of equipment, but, like all things with government, sometimes it is easier to give a one-off capital grant than make a commitment for the ongoing, recurrent funds that are needed. Unfortunately, what we need is recurrent funding to put more Aboriginal people through that health worker training course and so get them out into the community.

CHAIR —Is that the main thrust of what you will be showing us on Wednesday?

Mr Robinson —That is just an aspect of what we will be showing you on Wednesday. We are quite proud of our little training school and the quality of the candidates it is putting out.

Mr ALLAN MORRIS —That is the ASF2 effect. With regard to this argument about level 2 and level 3 that we have been hearing about, can you just go into that slightly and how you fit into that categorisation?

Mr Robinson —The course that we are running is an ASF3 course, and that fits within the national framework and meets the national competencies for Aboriginal health workers. Like all the employers of health workers in the Northern Territory, we are having, or will have, some problems, because we do have health workers who do not have the equivalent training to an ASF3, which puts them out of the revised Aboriginal health worker career structure, an award structure where you have to have the level 3 to actually start advancing up through the various grades. That is something that we have been talking about with Territory Health—about coming up with a combined program, or some way that we can assess our health workers and perhaps get them up to the level of ASF3.

Mr ALLAN MORRIS —For many people, the academic skills that are required would make it difficult for them. So far, we have heard this argument that the ASF3 level, particularly with regard to academic background and training, is not appropriate for a number of people, so people from remote communities will not be able necessarily to reach that level; hence they will never be able to establish an appropriate level with their own community members.

Mr Robinson —That is a problem that does exist. We have one particular person with 18 years experience as a health worker. He can do anything you ask of him, but he is still at that ASF2 level. There has to be some way of surmounting those problems, and they are very valid concerns to be raised.

Mr ALLAN MORRIS —The move towards competency based training and competency based assessments and so on would seem to be the way that it is happening in other disciplines. Is that happening in this area, and, if not, why not?

Mr Robinson —It is happening in this area. The course that we are running now is based on the South Australian Health Council course. It is very much into competencies; it has been targeted to fit in with the Aboriginal health worker national competencies. It is one of the reasons we changed from running the Batchelor College course to the South Australian one—more of that competency based training.

Mr ALLAN MORRIS —Two things have been said to us so far. One is that many Aboriginals will still be treated as second-class citizens in terms of being health workers, and that diminishes their capacity. The second thing said to us somewhere, possibly in informal discussions, was that the establishment of Batchelor—and we will be talking to Batchelor at some stage as well, by the way—has tended to make it more academic; that there is now a different agenda, which is an academic agenda rather than a community worker agenda, and that is in danger of locking some people out even further. So, whilst Batchelor has good intentions and good ambitions in terms of what it is trying to achieve, it may be inadvertently excluding a lot of Aboriginal health workers from being accredited adequately or being able to be effective.

Mr Robinson —That is a valid point, but I think you have to bear in mind also that those health workers that we in the Northern Territory call Aboriginal health workers are registered under the Health Practitioners and Allied Professionals Registration Act that exists up here and is administered by the Aboriginal Health Worker Registration Board. You cannot practise as a health worker in the Northern Territory unless you have that registration and a practising certificate.

What health workers can do in the Territory is quite substantial. They can take blood and they can do lots of other things—and I am sure you know what health workers do in the Territory. To do all that and to administer medicines—I am not saying prescribe, but administer medicines and explain to clients what the dosage rate should be—you have to have a modicum of understanding of the theory behind it, that is, the written language—

Mr ALLAN MORRIS —Yes, it has been put to us that many people are doing all those things with many years of experience. In fact they are saying that when they go, a generation of 20 years experience will not be replaced. They are doing all the things that are required of them, but they are not being paid and recognised appropriately and

therefore they are not being role models, if you like, for those who are less educated and to whom they could show a pathway. I suppose the concern was that the move towards academic qualifications can be counterproductive.

I am not diminishing the standards that are required, or the quality of care that is required; I am simply talking about the accreditation process and, perhaps, the misuse of people. We have been told that people are being misused; they are being treated as second-class. They are doing all the work, but they are not getting the same money and they cannot ever be accredited because their academic backgrounds are not adequate. They are good enough to do the work, but not good enough to be recognised for it. Is that a fair comment?

CHAIR —I would like Mr Robinson to respond on that.

Mr Robinson —There has been anecdotal history where, in some communities in the past, there have been people used as health workers who have not been qualified and who have been acting in those positions for some time. I could only say that at Danila Dilba all health worker employees are accredited and we do not employ health workers unless they are accredited.

Mr ALLAN MORRIS —I did not mean yourself, by the way; I meant in remote communities.

Mr Robinson —Yes, I realise that. I must speak primarily from my experience at Danila Dilba. The point you make is that being an Aboriginal health worker has not been a very attractive career. Basically, that gets down to the abysmally low wages that have historically been paid. We have tried in the past through the rebasing exercise and the introduction of our own award in the Northern Territory which covers our organisations—the Aboriginal health and other related organisations award—to raise the wage structure for health workers.

Where we came a cropper back in 1994 was in the fact that the Industrial Relations Commission had determined that the rate of pay paid by Territory Health Services was the community standard. That was the most the Industrial Relations Commission would pay. That has subsequently been changed and the problem now is actually getting funding bodies to provide the monies to pay to that appropriate level of health worker. For instance, currently we pay round about $22,000 to a newly graduated health worker. You are asking somebody to provide that type of primary health care: to get blood, to take blood, take obs, perhaps, and do some emergency stuff. It is horrendously low pay. Under the introduction of a new career and award structure, you would expect that to go up by about $8,000 and that is probably a little bit more realistic. Of course, then it goes up for other experienced health workers.

You are setting up a career path where you can progress and, by the attainment of

more competencies, progress up through the salary scale. That is the concept which, I think, we are all finding a bit difficult. It is not the old do a year and we'll up your grade. Then do another year. It is based on competency. So it is very quickly possible to move from a base grade up to the top of the level, and that may be a range of pay from, say, $25,000 up to something like $37,000. If you can demonstrate the competencies through whatever mechanism is decided upon, then you can go up that scale. That is difficult for governments to get their heads around as well.

The Office for Aboriginal and Torres Strait Islander Health Service has recently done a study into the costs of implementing a new Aboriginal health worker career structure. I believe that that report has now landed in the office in Canberra and we anxiously await the outcomes of that. That pointed out, for instance, that for the health workers we employ at Danila Dilba that are funded by the Commonwealth, we would be looking at around an extra $114,000 or $120,000 a year. That is to meet the revised salary structure for the six or seven health workers that the Commonwealth employs.

CHAIR —Where in particular would it have landed in Canberra?

Mr Robinson —It would have landed in the Office for Aboriginal and Torres Strait Islander Health Services. What they did there was help to establish some mechanism for introducing this. We are in a position whereby the Territory government has accepted in principle that they would fund community health services and the AMSs to that level. We are in the unusual position at Danila Dilba where half the work force is funded with money provided by Territory Health—I am talking health workers now—and the other half is funded by the Commonwealth.

We have taken the philosophical position that we are not going to have some health workers on $25,000 and some on $30,000 when they are the same grade and doing essentially the same work and it just depends what bucket of money your salary comes out of. We put that position to staff some time ago and we have been saying this same story now for about the past 12 months and we still have not got money from either. We are hoping that the consultancy that was undertaken by the Commonwealth will come up with some mechanism whereby that can happen.

We had a look at that at the congress at Alice Springs—in Wurli Wurlinjang at Katherine, in Danila Dilba and the Pintubi homelands. From the study of that the idea came that there be some mechanism applied over the other services that they fund in the Northern Territory for both the members of AMSANT and other organisations, such as Maningrida that they fund separately. We are all anxiously awaiting the outcomes of that report. We received our copies about a week and a half ago.

Mr ALLAN MORRIS —There was a question raised with us about DEETYA shifting its funding away from Aboriginal health training. Can you enlighten us on that at all in terms of your on-the-ground experience? I do not want you to compromise your

situation.

Mr Robinson —For the first year of operation of the training school it was half funded by NTETA and half funded by DEET or DEETYA at the time. That was a particularly horrendous experience and one we vowed we would try desperately never to participate in again. Basically, to get the funding from DEETYA, we had to accept their concept that the trainees going through would be from the long-term unemployed. The basic idea was that, if a person had been unemployed long-term and wanted to continue getting benefits, that person would do the course.

Luckily, we fought tooth and nail to have some say in the selection of those original trainees, but still they had to come from the long-term unemployed bucket. We felt at the time that that unnecessarily restricted our choice of trainees. We may still have ended up with trainees who may not have been 100 per cent committed to Aboriginal health, but it was a way of getting some training and continuing to receive some moneys.

That was our fear at the time. We went through quite a rigorous selection process. We rejected some whom we felt were just in it for the benefits. We were quite happy with the students from that first year. Out of 10 who started I think we ended up with eight who graduated, which is a particularly low attrition rate when it gets down to looking at, for instance, something like Batchelor College. We have maintained a reasonably low attrition rate over subsequent years.

Mr ALLAN MORRIS —Is DEET funding still there?

Mr Robinson —We do not have DEET funding at the moment. What we wanted was a free hand in selecting those trainees whom we thought would make good health workers.

Mr ALLAN MORRIS —So you lost the whole lot.

Mr Robinson —We went cap in hand to NTETA, put in a separate application, and they doubled the funding that they had provided previously, from $52,000 up to $98,000, which is still horrendously low for what we are trying to achieve.

Mr ALLAN MORRIS —Firstly, you may have heard me ask earlier the question about non-Australian doctors working in the Northern Territory. Secondly, are you aware of any Aboriginal doctors working in the Northern Territory?

Mr Robinson —I am not aware of any Aboriginal doctors working in the Territory.

Mr Ah Mat —There is one at the Royal Darwin Hospital.

Mr Robinson —That is right. He is doing an internship.

CHAIR —Which hospital?

Mr Robinson —Royal Darwin. We have had an Aboriginal student come through from the University of Newcastle who has done a placement with us in the past. Your second question was about—

Mr ALLAN MORRIS —Overseas doctors working on temporary medical visas.

Mr Robinson —We have not had any at Danila Dilba, although we have a web site on the Internet and quite often we get expressions of interest coming through from overseas from doctors seeking to work at Danila Dilba: I do not know what the procedure is, but to do a `penance' at Danila Dilba almost and then get some form of accreditation to actually practise in Australia. We have expressions coming through on the Internet from Pakistan, from Saudi Arabia, you name it—lots of countries from where people want to get into Australia. But all of our doctors are fully accredited to practise in Australia.

Mr ALLAN MORRIS —But from Sydney and Melbourne normally?

Mr Robinson —Normally from the eastern states, yes, and that does cause some problems with recruitment. We try to have a pretty rigorous selection process and it is a little bit difficult when we have not got the funds available to fly people up. Luckily, what has happened over the last couple of years is that we have actually had people ask to work for us as doctors, originally as locums, and they seem to like us, I suppose, and continue working with us.

For instance, this morning I met a new locum that is with us. We did not solicit. He had heard about what we do, checked out the web site and thought, as he was in Darwin for a couple of weeks on holidays, he would like to do a bit of work with us. That is the type of level of acceptability and how people are starting to know about us, and we are getting a lot of doctors now. I think there are another two applications from people wishing to be considered for positions with us.

Mr ALLAN MORRIS —Your doctors are short term or long term, on average? What is the average stay of a doctor with you?

Mr Robinson —We have had one doctor with us since the day we opened our doors, back in September 1991. The other initial doctor with the service is now doing a PhD at Menzies School of Health Research but still maintains an active interest with the organisation. We have two female doctors, both of whom are on maternity leave at the moment but they had been there for something like two years before they went on maternity leave. We have also had a doctor who went through the Royal Australian College of General Practitioners training with us and did his second term there, and has now come back to work for us. About the shortest permanent position doctor that we have there at the moment I would say has been there for something like nine or 10 months. So

we have a pretty good retention rate.

Mr JENKINS —When we visit on Wednesday, we will get a better understanding of how you go about your business, but how would you characterise your approach? I take it it is not a medical model, it is more a community health model.

Mr Robinson —Yes. We believe in the holistic view of health. If you come into the clinic, no matter how important or unimportant your problem may be, the first person you will see is an Aboriginal health worker. All of our patients see Aboriginal health workers first—as an aside, this is a bit of a bone of contention with PBS and MBS. The health worker takes your chart, takes your observations, listens to what you think your problem is and then makes an assessment of whether or not you need to be referred to the doctor. Approximately half of all people who come through the doors of Danila Dilba just see a health worker; it may be for something like scabies treatment, it may be that they need a flu shot or something like that, and the doctor does not necessarily need to be involved. We have senior health workers on duty, and we have one senior health worker each week who is rostered on to make a bit of an assessment about patients as they come through and we do some fast-tracking there. So that is the way we operate when you come in.

The standard consultation time at Danila Dilba does not fit into your long, short, medium, or whatever it is, general practice consults. We did a short study a year ago and the average time through the clinic then could be anything from 45 minutes up to two hours. Quite often if mum comes in with three or four kids we just do not see mum, we see the three or four kids at that time. They may be passing through Darwin, we may not see them again and we have to check up on all the immunisations, the growth rates and all of that stuff. That is the approach we have. While you are there, we have the opportunity to provide health education materials. Our health workers, especially those with particular interests, bombard you with good health information about diabetes, about whatever else you want. We have always maintained a very large commitment to making the resources available to the health workers and the other staff.

We have, employed by the service, a principal health educator who also coordinates the education activities. We have a women's health educator. We also have some male and female educators working the area of sexual health. We do not fit into the norms: we do that holistic view and we do the health promotions when we can. We try to test people for everything that needs to be tested. We check everything. We give people all of the immunisations that they need when we see them because we just do not know when they may be in our area again. This goes to that mobility thing again, as well as the population, and it has been one of the major stumbling blocks to our accessing Medicare. As I said, not all of our patients are seen by health workers and the whole health system seems to be so doctor based. You only have to look at the various programs around, be it the rural incentives programs or whatever, to see that they are all doctor based, and that has been a stumbling block to accessing the bucket of money that is called Medicare.

We have been negotiating on and off since Carmen Lawrence was health minister to overcome this problem, both by ourselves and later with AMSANT. I think we are getting there but it is going to take time and the whole process will have to be streamlined somewhat. As I said, our director is currently in Alice Springs furthering the cause, I hope, at this precise moment.

Danila Dilba is not a general practice. We do not claim to be; we do not set ourselves up to be. We are a whole of family service. In addition to these areas, and those that I have mentioned relating to training and health education, we are also in the process of setting up the emotional and social wellbeing program which is to do with counselling.

Mr Ah Mat —Just to cut in there, we also have a mobile patrol which goes to the town camps around the Darwin area.

Mr Robinson —The service visits 15 or so town camps daily. It also visits old people in their homes. Quite often we have the situation where the hospital discharges a patient and then asks us to take over some of that patient's care—for instance, checking up on their dressings and making sure that they are taking the medications that they should. That sometimes leads to a bit of a conflict because of the timing: it leaves a little to be desired when we get a phone call at five to four on a Friday afternoon. For us to adjust our resources at that late stage causes a problem.

The mobile service goes out once a day with a senior male health worker and a senior female health worker on board. The service also does some contact tracing for STDs and any other thing that other agencies need people to be traced for. A doctor goes out once a week with that as well. About half of their time is spent visiting people in their homes, and quite often they are the frail and aged.

Mr QUICK —How many people are on your books?

Mr Robinson —We have over 14,000 patient files that we deem to be active. I think the latest census that has been done shows that there are 7,000 or 8,000 Aboriginal people living in the Darwin, Palmerston and Litchfield local government areas.

Mr QUICK —Has there been an evaluation of just how effective—I am always on about longitudinal studies—that service is so that you can say to someone in Canberra or Darwin, `Look, X number of dollars is being spent wisely, because the incidence of STDs within our client group has diminished from so many per thousand down to such and such, and the immunisation rate of our children is such and such.' Do you have those figures? When they are handing out bags of money, that is what Canberra bureaucrats are looking for.

Mr Ah Mat —That has been one of the things that, as a committee, we have been trying to come to grips with—in terms of finding out how effective we are. With the

limited resources that we have our focus is at the other end rather than at the end that you are suggesting.

Mr QUICK —We have discovered that, even with hospitals, the people who are collating the information are usually the first people that disappear when the hospital restructures so that the bare statistics are not there. One assumes that, if you are operating under this holistic approach, this is probably one of the key things that you need to have to convince people to change the MBS or PBS schemes, because you could prove to them that this is far more effective than the doctor driven approach that the health departments are on about.

Mr Ah Mat —Our approach to that has been that, prior to our establishment, where did these people go? It is clear that the people were not going to the services that were already in existence. Now that we have established ourselves, people are coming to us. They just were not going to see the other health services before that.

Mr QUICK —How responsive is the Northern Territory government to saying that as part of the health education issue they ought to give you some money so that you can set up some longitudinal studies to follow, say, a 16-year-old woman for 10 years to chart not only her health but also the health of her family? In that way you can get some statistical information from which you can say that it is proven that compared to the GP based system that is working in other areas the holistic thing is working here.

Mr Robinson —I think we accept your supposition there. It would be great if we at Danila Dilba were able to do some of that ourselves. We must bear in mind that, when we were established in 1991, we had a staff of seven, of which two people were involved in administration—that is, the administrator and the director of the service. Since that time, we have gone up to a staff of 50. After the interviews for the emotional and social wellbeing program are completed this week, the number will probably be around 55. But we still only have two administrative staff. When Pat goes to Alice Springs and I come here that is it: there is no-one else in administration at Danila Dilba at this precise moment. That is where we have come up against a brick wall, getting the support to look at the administrative side of the service and getting somebody here to pull out the data that we collect. We collect the data; it is just that no-one has any time to do anything with it.

The service is growing in leaps and bounds. We see 1,200 to 1,400 people a month. When we first started with the same two administration people, we had 100 people go through the doors in the first three months and we thought we were going great guns. Since the transfer of Aboriginal health from ATSIC to OATSIHS, we are constantly asked, `What are the mechanisms for expansion of services?' Expansion of the services is just not that clinical site; there needs to be coordination. I am getting to the stage where I am sick of working from 6.30 in the morning until 6 o'clock at night, five days a week and then coming in on the weekends to fix up the watering system. There has to be greater capacity in the organisation to do these other things you are talking about, to look at the

stats that are there and to come up with these ideas to government. It is very circular. We need the information to get the money, but we need the money to get the information.

We have talked about these with Territory Health Services as well. The response there is basically, `You are funded by the Commonwealth,' or, `Speak to the Commonwealth.' The answer from there has been, `Use Medicare.' We have talked about the problems that we have had with that and we have to sort those out first.

Yes, the studies need to be done and I am sure that if they were done, you would see that we and the AMSs are providing value for money. I think we provide a very cheap primary health care system to the people who come through our doors. It is only going to be stuffed up now by the goods and services tax.

Mr JENKINS —That is a very opportune time for me to come in. There are a couple of levels that I want to go on from your description of where you are at at the moment. There are two levels. One is the internal level where you have described the model of how the community controls the service. You said that the committee's role is to worry on behalf of the community but not to interfere in the day-to-day running of it. Is there a clear demarcation in setting priorities or areas that you would like to expand into? Is it integral that the committee be involved in the setting of the priorities or setting the dimensions of the vision of the organisation?

Mr Ah Mat —We have a number of subcommittees operating at community level, and we have asked others to come and join us to work on that so that we can set the priorities ourselves. We can then pass that onto management and the management takes up that role.

By operating as a committee, we are able to get advice on what are the concerns and the problems in the community, and we can then set directions which are clear and precise. We can say, `These are the problem areas that we are experiencing now. This is where we need to start focusing our attention and our resources.' What we are faced with here is that we have to wait for someone else to provide a report to government to highlight the illness in the community and then we can access the programs as the dollars become available for that particular program, but it becomes a body part type of situation.

We are not fully in control of our own destiny. We need to be able to look at our community at this level and say, `This is what we need to address next.' So that is the problem that we have. We need to be fully resourced so that we can make good choices. At the moment, we cannot make those good choices. We are restricted. The options that we have available are restricted by the programs that are coming out in terms of whatever the illness may be.

The other point is in terms of the cultural aspect of how we want to do things. We gave the example of DEETYA wanting to get involved in the selection of health workers.

What we are trying to do is to allow the community to put up the people who should be the health workers. Only very recently we took on some Torres Strait Islander trainees. They were, in a roundabout way, put up by the Torres Strait Islander community.

Mr JENKINS —How much of a problem is it if you want to concentrate on wellbeing rather than on illness?

Mr Robinson —Our philosophy—and I think it is in our constitution—is very much about wellbeing. There is the matter of the lack of resources of the service. I am not belittling the efforts that successive committees have made in obtaining resources or the efforts of the office which funds us. What we are still doing is scratching the surface of the illness. Health education people cannot do as much as we want. We are constricted by that area. A lot of people think that you get into education and the illness disappears overnight. It does not. You cannot take funds out of one and do the other. You have to do both concurrently. We just have not been funded at the appropriate level to do it. We are still treating the illnesses without looking at the prevention side of things as much as we would like to.

Mr Ah Mat —Also, there is a perception that because we are in town the health services provided are much better. That is clearly not the case. A lot of the resources get sent out to the communities, or that seems to be the target. Danila Dilba has been at the forefront of trying to highlight the concerns in urban centres as to what the issues are.

Mr JENKINS —You gave an example of the problem of day-to-day coordination with other agencies—for instance, on discharge from hospital, being told at the last minute. My question is more directed at planning and coordination. What avenues or mechanisms are available at Danila Dilba to be involved with other agencies, whether it be at the territory level or at the Commonwealth level, or even with other NGOs, about the provision of services?

Mr Robinson —Danila Dilba is a foundation member of the Aboriginal Medical Services Alliance, which is one of the four partners in the framework agreement in the Northern Territory, along with the Commonwealth Department of Health, the Territory Health Services and ATSIC. At the moment, the chair of the state forum is the Director of Danila Dilba, Pat Anderson. I believe that we coordinate with those other partners at that level. In addition, Danila Dilba, along with the other largest AMS in the Territory, which is the Central Australian Aboriginal Congress, is a core partner in the cooperative research centre in looking at Aboriginal and tropical health, along with Territory Health Services again, the Northern Territory University and the Flinders Medical Centre.

We do participate in these forums and raise our issues, and there is some form of cooperation and coordination. In addition to that high level stuff, the service is a member of NACCHO, the National Aboriginal Community Controlled Health Organisation; we have been particularly involved, both as Danila Dilba and AMSANT, in its incorporation.

AMSANT members hold three of the executive positions on NACCHO, and we get our point of view across at that national level.

The Territory has been particularly strong in lobbying. We were one of the organisations of Danila Dilba and the Territory in particular that lobbied hard and long to get health transferred from ATSIC to the Department of Health and Family Services. We were quite successful in that. So that is the national level at which we participate.

At a local level, our clinic manager and the director, when available, meet with the other community care centres around the Darwin area to talk about coordination problems. We also meet and talk informally with the other Aboriginal health agencies around town. So there is that level of coordination, we believe, at the different levels. We are at the stage that, if we have a problem, we are in a position to get on the phone and talk to Peter Plummer at Territory Health Services, for instance, at that level, or to Trish Angus or the minister's office, in order to work out some way of sorting out any problems we could have.

The whole question of coordination was actually raised in a report that we commissioned several years ago, called It's not good enough to know about diseases . It was highlighted then that there needed to be greater coordination between the services, and we have worked towards that. I will give you an example. They are reviewing the Mental Health Act here in the Territory, and part of that is reviewing the criteria for admission. They have established a series of working groups to look at each of the criteria. Eighteen or so working groups have been established, and we have been invited to participate on 15 of those 18. Clearly, that is taking coordination a bit overboard: we cannot spread ourselves around to that level.

So there is a willingness but, once again, there is the whole question of resources. We cannot do everything. Territory Health Services have hundreds of people. They can set up little specialist committees all the time. They can invite us to participate, but there comes a time when we have to worry for Danila Dilba and keep it on track and keep it running efficiently, without participating in all these other forums. We have been criticised in the past for not fronting up at some particular strategy group meeting or other, but we cannot spread ourselves around. As I said, there are just the two of us, and we cannot go much further than that. So the real problem in that coordination, for us, is simply people time.

We are finding now that we are employing our doctors to get submissions done and reports read, and that is basically a waste of their time. They are the most expensively paid members of the organisation. The fact that they are doctors does not necessarily mean they have skills in research, report writing and all of that. We have to look at the way we can operate. With greater resourcing in the administration area, we will be able to participate and coordinate a hell of a lot more.


CHAIR —This inquiry is unusual in the way we are conducting it. We have brought Jim Kennedy in, seconded from the department in Canberra, and Puggy Hunter from NACCHO has been accompanying us around on our visitation; so we are trying our best. One of the recommendations has been the need to have regional forums, but I have just heard you say that you are so busy delivering that you have not got time to assist in planning for the longer term. What is the answer to that? Resources, obviously.

Mr Robinson —That is a problem. It is difficult to participate. Two or three faxes marked `Urgent' come in each week asking us to participate in some forum or meeting being held somewhere in the country. For us it is not just a case of hopping on a plane. If you are in Sydney you can fly to Canberra in 20 minutes. For us it is a four- to five-hour plane ride, quite often with a stopover of a couple of hours in Brisbane or Sydney. An Ansett flight leaving here at that dreaded hour of 5.55 in the morning means getting into Sydney or Melbourne at perhaps 3 or 4 o'clock in the afternoon. So, for a one- or two-day meeting, add a day's travelling each time.

And we have to weigh up whether our being away from the organisation is worth the benefits achieved. There are some things that we should be doing that we just do not do because of lack of resources within the organisation. It would be great to be able to go away for a couple of days and know, for instance, that the mail box is being emptied. It is things as basic as that. When I say there are only two of us, there are only two of us. We do not have a secretary or an administrative assistant. Pat and I are probably the most expensive people to sit down for an hour and do nothing but photocopy handouts because people may visit the clinic.

CHAIR —I hope our visit on Wednesday is not seen as an imposition. We could do some photocopying while we are there.

Mr Robinson —If you know how to push that button, feel free.

Mr Ah Mat —I would like to make a comment in relation to the Northern Territory government. Of the health works that have come through our school, I think the majority may have gone over to the Northern Territory health department. The Northern Territory health department spends a lot of money on Aboriginal health, but to a lot of us it is unclear where that money is being spent. We see a lot of health workers in the hospital areas, but they are not actually in the hospital system. It is really difficult to work out what it is that they do there. Some are on specific programs, but it is unclear as to what they are doing there. That is something that may need to be investigated to find out where the dollars in Aboriginal health are being spent so that community controlled institutions and remote communities can get a slice of these dollars. Our workers are leaving us because our salaries are lower than those in the department. They do not have to do the same sorts of things they are doing at Danila Dilba but they can get more money.


Mr JENKINS —What role is there for mainstream services outside hospital or tertiary care? We have received a lot of evidence about the need for things done there to be culturally sensitive. There must be things that even in your wildest dreams you could not see yourselves getting sufficient resources to be able to do, so you must be reliant upon other providers. What has to happen to those other providers to make them able to deliver a quality service to indigenous Australians?

Mr Ah Mat —There was a clinic at Berrimah. Just down the road from that is Kormilda College, which has a fairly large contingent of Aboriginal students from remote areas. They chose to use us. In fact, their parents said that they wanted their kids to come to us because of the appropriateness. We have said before that our numbers are around 14,000. Where were these people going before? If they were going to the NT health service, what is that service doing now that there is this huge decrease in numbers? They are the sorts of things that we often talk about. They are still getting the same amount of dollars and we are constantly waiting for another body part program to come up so we can try to access it. We had a new member join us recently on the committee. At each meeting we have financial statements presented. At the moment we have 20 accounts that we have to administer because they are all from different programs.

If you are interested in helping to resolve indigenous health, they are some of the things that need to be addressed. Instead of us applying under a certain program, we are saying, `Give us an amount of money so that we can go and do what we have to do.' It is important for us to do what is needed in the community—not to respond to another report that has caused a lot of hullabaloo by saying that kidneys are the problem, so there is a large emphasis and a lot of money spent on kidneys until someone else comes up with another favourite body part that is special to them. We are trying to look at people in their entirety and yet we have to constantly chase programs in this manner.

Mr Robinson —Having that large a number of programs is an administrative nightmare. We have tried, as well as we can—again the problem has been the availability of capital money—to set up systems such as the accounting system and the IT system to compensate for the lack of bodies on the ground.

Mr QUICK —Is it realistic to have one model for Aboriginal health? Some of us think that perhaps we should have a Redfern model and Wilcannia model and an AP Homeland model.

Mr Robinson —It is like saying that there is only one Aboriginal group of people, and that is clearly not true. There are a lot of different nations of Aboriginal peoples around the country. You cannot have just the one model. It has to be specific to the region, arising from what the community, through that thing I spoke about at the very beginning, has determined that service is going to do.

Mr QUICK —Are OATSIS and the Canberra bureaucrats still thinking of one

model for Aboriginal health? Is that lack of flexibility the problem—the inability to access MBS and PBS to say that what they need at the AP Homelands is completely different from what they are going to use in Redfern?

Mr Robinson —That is a problem.

Mr Ah Mat —There are certain aspects that can be standardised, for example, the reporting mechanism. You could standardise that. But how we operate on a day-to-day basis is our business. As long as we maintain our reporting—and our record on reporting is impeccable—our job is to look after people's health. Let us get on with that. Let us not chase dollars and go to meetings that sometimes we feel we have to go to to make contact with people to find out what the next lot of money coming out might be. Chasing this stuff around wastes the time of the director and administrator. You asked us about our needs. That is far more important to us than running around the country doing silly things.

Mr Robinson —Your question about the flexibility of funding is crucial to this. Unfortunately, it is quite often you guys who are insisting on that through accountability to the various departments, the National Audit Office, et cetera. In my original discussions with various officers in ATSIC and the Department of Health and Family Services they did see the need to be a little more flexible to take into account the various needs of the services, but unfortunately programs are not designed that way and out come the application forms and you get it. If you do not conform to that you are out of the running.

Mr Ah Mat —If we are talking self-determination, we should be able to determine how we spend the money and what our priorities are. If we do not report correctly or if we misuse that money, then close us down. Get someone else to do the job. It is as simple as that. Do not keep us on a short lead that is jerked every time someone has a disagreement or a new body part comes online.

Mr QUICK —Are the Territory government and the Commonwealth being a little bit more flexible at this stage, or are they both set in concrete?

Mr Ah Mat —They have their moments.

Mr Robinson —Yes, they have their moments. With the funding from Territory Health, the letter of offer we get is quite flexible. It says `assist in the provision of clinical services'—which is very open-ended. The Commonwealth one says `operation of clinical services'. We do have flexibility there; but, while saying that we have that flexibility, we are still expected to put in a budget that clearly lists what the line items are between capital recurrent and salaries, and we still have to get permission to transfer any moneys between them. An example of that is that I went away on holidays for eight weeks last year, for the first time in about five years, and we actually filled my position by getting a temp. We then had to seek a budget variation to transfer that amount of money from


salaries through to whatever, to cover it.

To my way of thinking, that was ridiculous but it was something we had to go through. There has to be greater flexibility than that. I totally agree with what our chairman is saying. We should be given that bucket of money. We should set the priorities and determinants, as long as we do not misuse the money and—I take your previous point—as long as we can demonstrate value for money in providing a good health service delivery. Perhaps the two go hand in hand.

CHAIR —I propose a short break now. We look forward to talking with you some more, John and Lindsay. Thank you very much for your time today. You have basically come in to affirm the alliance's submission. It has been good to have a chat with you before we have a detailed visit. We look forward to seeing you on Wednesday.

Proceedings suspended from 11.12 a.m. to 11.31 a.m.