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

CHAIR —Welcome. Do you have anything to say with regard to the capacity in which you appear?

Dr Glasby —Although the submission was written on behalf of the Top End Primary Health Care Network, that project as such has ceased to exist under the auspices of the Top End Division of General Practice so I am essentially speaking for myself as a public health trained GP and a reasonably long-term resident in the Katherine region with some experiences from my time as the project manager for the Top End Primary Health Care Network.

CHAIR —Whilst this committee does not formally swear its witnesses, the proceedings today are legal proceedings of the parliament and warrant the same respect as the proceedings of the House of Representatives itself. Any deliberate misleading of the committee may therefore be regarded as a contempt of the parliament. This also serves to protect you and the evidence you give, which is covered by parliamentary privilege.

As you have mentioned, the committee has received the submission you referred to and it is part of the published volumes of the inquiry. The committee is very much interested in talking to you as someone who has been at the coalface. I am particularly interested to talk about your experience and how you actually came to work in the Top End and, contrary to popular opinion, the difficulties you had in getting a position as a new doctor. That is the kind of thing I would like to pursue with you. In fairness to you, though, we will give you the opportunity to make an opening statement to canvass the sorts of things you would like to submit to us—it is nearly 12 months since you wrote your submission. I give you the commitment that your evidence is as important as any other evidence we have received, and we have heard from people all over Australia.

This is an unusual inquiry in which we have broken a few of the normal traditions. We have had Puggy Hunter from NACCHO accompany us on our inspections. Jim Kennedy has been seconded from the department to spend time with us as a parliamentary committee. We have a strong bipartisan resolve amongst the committee members to make some progress on this matter and keep the politics out of it. That is how we feel.

Mr ALLAN MORRIS —Give up the GST.

CHAIR —There is time for that as well. You have met the whole of the committee. I have not taken the trouble to introduce the committee today because we have been coming and going. Harry Quick, the member for Franklin in Tasmania, is the deputy chairman; Allan Morris is the member for Newcastle in New South Wales; Harry Jenkins is the member for Scullin in Victoria; and I am the member for Mallee in Victoria, which

is a large rural electorate. We have a very diverse group of people and there are another eight or nine members who cannot accompany us for every visit.

That is us, so now it is over to you. You have as much time as you like as there are a few witnesses who have not shown up today. It is your opportunity to indicate some of the frustrations you have felt and for us to try to get them on the record and try to do something about them.

Dr Glasby —Thank you very much for your welcome. When I look at my paper in relation to some of the others, the amount of work people have put into this is fantastic. It is really good to see the expertise that you are being exposed to.

As an introduction, I was project manager of this primary health care network because I was one of a few GPs working in a bush community who could take it on. The previous project manager, who lived in Gove, wanted to hand it on to somebody who worked in the community to maintain this rural aspect of it. When my wife and I—she is a medico too—were living in Daly River under an RIP grant, I was able to take up this job as part of my part-time work. My wife and I were job sharing that position so I was able, in the other part of my time, to take on the project work associated with the primary health care network, which is in front of you.

It attempted a multi-disciplinary approach, primarily involving Aboriginal people. As GPs working in the bush, if you do not have a health worker working with you, most of the time you are severely handicapped. This project was actually an initiative of GPs working bush who said, `We need a team around us. We can't function without the Aboriginal health workers and the nurses. We believe that the current situation', as it was, and is again, `is inadequate to provide us with the supports required to work effectively in those situations.' This was a Commonwealth funded project which has now, through the evolution of the divisions and project grants, become something different. In that brief introduction you might pick up a degree of dissatisfaction with the existing services provided by the local health department.

I also want the committee to understand I am very positive about the things going on within Territory Health Services. In this area I believe Territory Health Services is not adequate in being able to provide resourcing or planning to really provide for Aboriginal people out bush. I probably do not have as much experience working in bush communities as Chris, but I worked within Aboriginal medical services before in Daly River for a few years. I was trained in public health before we came back to the Territory. I was an intern in the Territory and I also worked in Alice Springs. We lived in Melbourne prior to that. That really did not suit us and we either had to go back to India, where my wife and I both grew up, or stay in Australia. I have two brothers in the Territory so it seemed a good place to come back to and be able to be useful. I think that is where we stand. The social justice issue of working amongst Aboriginal people is important. That would be our aim basically.

We came to the Territory to work amongst Aboriginal people, preferably in an Aboriginal community, and we had to wait three years before a suitable opportunity came up to be able to work in the bush.

CHAIR —So much for the shortage. What year was that?

Dr Glasby —It was 1993, 1994 and 1995. In that time three other positions came up. Two that we applied for were taken up by other people or were offered to other people, and one was only offered after we took the job that I took in Katherine at the time of Wurli Wurlinjang. So there was not a real shortage in the Top End. But, again, I believe that is because Territory Health Services really did not collaborate with the Commonwealth in the rural incentives program. If the Territory had taken up the rural incentives program and really promoted it and supported it, I believe it could have facilitated the placement of GPs in communities far more than has actually happened.

I have worked intimately with the Territory Health Services for the last few years as a doctor in Daly River—I had to, because we were intimately connected. The doctor who had been there before us at Daly River was a DMO and worked for Territory Health Services. The nurses all worked essentially in the same model as Territory Health Services nurses work, although they were employed by the community in a grant and aid situation.

What I tried to set up in the first paragraph of my inadequate submission was the fact that I believe the Territory Health Services—even though I appreciate so many things that they have done—do not have a handle on being able to provide Aboriginal people with what they really require. Also, the Commonwealth needs to get a very clear message from people on the ground about the adequacy of health services. I do not believe state and territory funded health services are adequate. This is backed up by international reviews of indigenous health funding which all suggest that, if you want to go ahead with indigenous funding, you have got to stay with Commonwealth or federally funded activities.

Earlier somebody asked the question of another person who was sitting in my position: how did the Maoris and the Indians manage to improve their situation more than Aboriginal people have improved their situation? Kunitz—I am sure the committee is aware of that name; it has probably been mentioned on a number of occasions—very clearly showed up in his work that the differences are partially, at least, if not more importantly, due to the fact of Commonwealth and federal funding for indigenous health services in those countries. I believe that our country has no other good model to follow at this stage.

That is a bit of an introduction. When I read my submission again now I find myself cringing in terms of some of the points I was trying to make. Although I am public health trained and I am a medical practitioner, I found it tremendously difficult to try to grapple with the jargon in ads placed in the paper. Most of my colleagues very sensibly

disregarded the jargon and just answered the questions, saying what they thought were the problems with Aboriginal health. I believed that I should try to address them, so I made a series of comments. It is fairly hard to pick the guts out of them if you want to.

The point I want to make again is that, if you want to look at a funding pattern that makes sense to people on the ground, you have to stick with a Commonwealth funded program, although there are arguments for and against that. People in Queensland seem to be working very effectively together—I am not sure how much. Western Australia has a reasonably good record. The Territory is a very immature place in terms of the development of services. They will not have told you this morning how many reviews of the Territory Health Service have been performed in the last 10 years and how many recommendations of those reviews they have managed to carry out to make health services more appropriate in the Territory. But I will tell you for certain that they have not been aimed at rural activities. We will come back to that later, I am sure.

Mr QUICK —If we said to the Territory, `Okay, we are going to pull out X millions of dollars and it is going to be a Commonwealth responsibility,' the Commonwealth does not have representatives out in the areas so there is no-one necessarily in Darwin, Katherine or Alice Springs, so do we have to replicate another bureaucracy which in lots of cases is probably just as inefficient as the Territory's or a state's?

Dr Glasby —I am not as pessimistic in terms of another bureaucracy. I think that health boards around the Territory have indicated the possibility of independent health services being able to operate without another layer of bureaucracy too much above them. Nganampa Health Service is a model. I am sure it has its faults, but it has been operating now for a number of years and is a good regional model of health service delivery to Aboriginal people separate from states and territories, as I understand it. I stand to be corrected.

Mr QUICK —Do we say that its $57.63 per person should provide an adequate health care cover for one year and that, multiplied by X number of patients, health board A gets $1.7 million for all the indigenous people in Katherine, and we then leave the health board to sort out priorities? Have you seen a model that is approaching the ideal that you would like to run?

Dr Glasby —All of the Aboriginal run health services manage without an extra layer of bureaucracy. I am not sure whether I am speaking out of turn here but, essentially, the independently run health services are granted moneys and they operate health services. Congress is a very large operation that has no extra layer of bureaucracy above it, and it is directly funded by the Commonwealth, as I understand it.

At the moment I am working as the public health adviser to the Katherine West Health Board. I believe, with the model that is being generated there, we are struggling to


come up with something that is at least as effective as Nganampa is. We would see this as very important developmental work in terms of health service funding. In terms of models for actual funding, it is likely to be more beneficial than any funds that you direct through to the Territory now, half of which get gobbled up in the bureaucracy. Actually, it is more than half.

Mr QUICK —Following on from that, you need money for housing, which is not necessarily in the health department, and you need access to money for education. So how do we marry in all these departmental boxes? As well as getting health money, you get educational money, you get transport money and you get housing money to give to community A so that there is a holistic approach to health, so they have got adequate housing, sewerage and roads and all that sort of thing for the community? It might be easier to deal with health, but how do we get all the others? Do we say to the Territory housing department, `Look, we're going to take money from you that previously went to Aboriginal housing and put that back into this new basket of money and the Territory transport department, or local government, because you are not adequately servicing the roads and things'? Do we pick all this money out of all these baskets?

Dr Glasby —One has to be factual in these matters. Lots of communities have reasonable roads to them and, more importantly, they have bitumised roads within them. That is the issue in terms of roads, more often than not. But, once we are talking about those more general infrastructure areas, any one person to speak on that would have to be careful to know where the bubbles were coming from.

I think you have to go back to community control. This has been said a thousand times before, and I have written it again, and where I am working at the moment I focus on it. You have to have community control as a requirement, and then you have to actually educate the community to be able to participate effectively as a community controlled organisation.

When you go to the Tiwi islands and when you come to Katherine, you will find out about the amount of effort that has been put into educating people to be able to function as board members. When people talk about education—and you are well aware of the problems inherent in most Aboriginal communities in terms of eduction—that is not going to change overnight.

Mr QUICK —In his PS, Dr Harrison said:

I have just received a nice glossy 100 page document from OATSIS on reporting requirements.

He is struggling with that, and he is frustrated.I am not being disparaging, but what will Aboriginal people—who might have had a grade 7 or 8 education—make of this 100-page, glossy OATSIS document that they, as a community, have to work through? As Dr Harrison says, the state health department put out a similar sort of thing but, quite often,

they do not even talk to each other.

Dr Glasby —I do not believe that is a real barrier in some ways. I work with an Aboriginal administrator who eats those things for breakfast so there are varying levels of skills. What you are actually setting up with regional health bodies is enough resourcing to provide Aboriginal people with expertise to be able to cope with these things. I believe that that is the model that Nganampa works on; that is the model of the organisation I am working in at the moment and these are working models.

We have established within Katherine West health board that we want to work in an action research way—which is a little bit up in the air—but, essentially, you do certain actions and you look at it. This follows Mr Morris's suggestions about how you incorporate research into your clinical activities as a GP out bush. We are developing a working model and I think that that has to be something that we actually struggle with, this whole area of going forward as a GP working out bush. You get deskilled out bush; you are removed from a lot of professional contact in other ways and these kinds of incentives may—I have not read the recent reports that have come out of the GP Review for Rural Activities, but I have not seen anything that looked as sensible in terms of your career opportunities as a person working in those situations. I am not sure. Chris, have you read those?

Dr Harrison —Just generally.

Dr Glasby —Action research provides a basis for this.

Mr ALLAN MORRIS —The perception has been that it may well hurt your career to have worked in the bush: that you may well have done it because you could not get work somewhere else and because you were somehow a bit off the planet.

I will tell you a story about a student I knew once who took a year off medicine and came and worked in the Northern Territory as a fourth year medical student. When he got back I said to him, `That was a really strange thing to do.' I asked him about it and said, `Won't it hurt your career?' He said, `All my colleagues think I'm mad. They think I've wasted a year's income.' And I said, `But how about your studies?' and he said, `That's easy. That's not a problem.' All of his colleagues at university thought he was stupid because he took a year off, which meant he lost a whole year's income as a doctor in two years time. That was the perception and it probably still is. You go bush for a few years and it looks like you have gone to live like a nomad and you have gone backwards while you have been away.

Dr Glasby —There is an element of that but there is actually a large body of medically trained people in the Northern Territory who have worked bush.

Mr ALLAN MORRIS —But there are no psychiatrists. Look at all the specialities

you are missing out on.

Dr Glasby —There are psychiatrists. There are not many but there are a couple of psychiatrists.

Mr ALLAN MORRIS —Are they permanent?

Dr Glasby —They live here.

Mr ALLAN MORRIS —I have a recollection particularly that when we were looking at youth homelessness, there were no psychiatrists here then.

Dr Harrison —I do not think it was said that there were none.

Dr Glasby —There is a great paucity of all specialities, certainly.

CHAIR —Dr Glasby's wife is also a medico so that is even more unusual.

Dr Glasby —That is not necessarily so unusual, Mr Forrest. There was another team at Maningrida who also made a submission. Mike Dawson and Margaret Niemann were at Maningrida for a couple of years. It is not so uncommon for medicos to marry but still, we are not necessarily the commonest folk.

CHAIR —I did not mean it like that; it has been a long day.

Mr ALLAN MORRIS —In terms of your career path in the sense of a career as professionals, the fact is that for you to progress your career as such you have to leave the Northern Territory.

Dr Glasby —As I was trying to say before, there is a large stable body of general practitioners in the Northern Territory who work collectively and recognise each other as professionals. There are, of course, idiosyncrasies amongst that group of people as there are within any group.

Mr ALLAN MORRIS —But if you are going to get funding for research or from the National Health and Medical Research Council or the national institutions, then the accreditation that you need and the professional standing in which you are held by your peers will not be augmented by staying here, I would have thought. That would be gained somewhere else. Isn't that the history of things?

Dr Glasby —There is an element to that but, as Professor Mathews mentioned today, they have a body of researchers there who have been general practitioners. That is the only option.


Mr ALLAN MORRIS —I am trying to look at a different paradigm. We have to work out a way to move forward and I am pressing all of you with these questions. The model has failed to date. There are all these pages of research and we still do not know what has caused kidney failure. All that work that has been done still does not have a result in a professional, medical and biological sense.

I am trying to suggest that somehow we have to find a new way of doing it. Medicine is as faddish as anything else, if not more so. Black health is not exactly fashionable right now. How do we try and give it status and significance? In any other Western country an epidemic such as is facing us here would be a major front page national story; yet here it is backwoods, backyard, off budget, `let's not talk about the war' stuff. This is all of us. This is a national problem, not a Northern Territory problem.

Dr Glasby —To focus on the issue of taking it forward and career structures for those of us who are interested in working in those situations, I believe your suggestion of involving research as part of your duties in those positions is a reasonable activity in terms of career advancement and the placement of GPs in communities, but I will qualify that. I am not sure that putting GPs in communities is necessarily a workable a model in a short-term framework. We have been trying to put GPs in communities for the last four or five years.

Mr ALLAN MORRIS —And we have failed, yes.

Dr Glasby —But we need all kinds of input as to what kinds of incentives can be generated which are more satisfactory, because the current incentives do not seem to be.

Mr ALLAN MORRIS —So far we have had two options raised, not today but at other times. One has been to pay them more, in other words a financial conscript, and the second one is a career option by saying that they must do two years service in the bush. That is like the Queensland teachers or the old New South Wales teachers bond model. You do not get accreditation or you get faster tracking for your Medicare numbering if you spend a couple of years in the bush. Those are the two models that we have been given so far. To me both of those are very unprofessional and very bad for the people in the bush who are being treated by them.

Dr Glasby —It misses the fact that what you have got is an interaction with an Aboriginal community which is not considered in both of those incentives. To qualify that even further, I believe all of these programs need to have a multipronged approach. You cannot rely on one or two incentive type programs. You have to have a range of incentives depending on the individual and the situation. Particularly in Aboriginal communities there needs to be certain other infrastructural work done so that the community can own the health programs, rather than the doctor being expected to be the boss.

Mr ALLAN MORRIS —We were told in an inquiry two years ago that temporary

medical admission was the only way they had a medical service at Halls Creek. We had a hearing in Darwin on access and equity. We were using overseas doctors who would not be professionally recognised in Australia otherwise. That was the third model.

I think they are all wrong. All the models we have used are not good for the people involved. They are all good for the person who is providing the service. In other words, a visiting foreign doctor gets a higher wage while they are working in Australia for a period of time. With the other two get career enhancement for themselves, but none of them is good for the people actually being treated.

I have raised one model today, which is GP research or the service provider, and questioned that as a possibility. Do you have some more for us? We need more than one, but how many more are there? Do you have any more you could put forward?

Dr Glasby —Again, there is no single one I believe will be successful.

Mr ALLAN MORRIS —There is Dr Harrison's coordinated care trial where the doctor is part of a team which is cashed out and where the financial situation is different. That is another one.

Dr Glasby —Indeed. The whole idea that Medicare in the Territory is inadequate needs to be supported.

Mr ALLAN MORRIS —Yes, I agree with you.

Dr Glasby —There have been several other submissions which have made it very clear that Medicare is a major problem here. I did a rough calculation before as to how many GPs are working on salaries in the Top End only. There are more than 10. I counted about 15, and that is not counting the district medical officers, who are salaried officers under the Territory Health Services. We have got close to 15 GPs who are essentially working under a salary type structure and Medicare is a component of it in one way or another. If you asked those GPs whether they would be happier to work in a decent kind of salaried position, I know what their answer generally would be.

Mr ALLAN MORRIS —I am sorry, I do not know the answer.

Dr Glasby —They would be very happy with a situation that clarified what their income was going to be, without all the hassles associated with Medicare.

Mr ALLAN MORRIS —We had a submission from somebody else that suggested the idea of a private company type basis.

Dr Glasby —There would be a number of models. Mike Owen—


Mr ALLAN MORRIS —It was stated:

Private, multi-doctor, sub-regional practices should be supported as viable private enterprises, even as Aboriginal Enterprises, to avoid creating more politico-health qangos.

I thought about that and I am not sure that I agree with either of those, actually. Of course, the coordinated care trial could be seen as a politico-health quango. On the other hand, a multi-doctor private practice could be equally seen as being not much different. But you are saying the salaried doctor would be a workable model for the Territory?

Dr Glasby —I would qualify it by saying the Top End. I can only speak for myself. But I am telling you that there are 12 to 15 GPs who are primarily working under salary based conditions in the Top End.

Mr ALLAN MORRIS —And there is some uncertainty as to salary value?

Dr Glasby —Yes. There are quite variable packages involved.

Mr JENKINS —You made reference to something that Michael Owen said.

Dr Glasby —Yes. Michael Owen proposed that you have variable Medicare rates depending on isolation and so on, so that you would get a different rebate for working in different places. That has probably been proposed before, but this morning was the first time I have read that, when I got a chance to get my hands on the paper. I think your job is to look at all the various options.

Mr ALLAN MORRIS —That is not an option. We should be about equity for people when they need the care, not—

Dr Glasby —If you are talking about salaries as an issue, you have raised the issue that, if you pay them too much, then they are going to come, but they are not going to be really committed. I do not believe it is going to make that much difference. I think that GPs who are interested in a social justice issue will come whether you pay them $100,000 or $180,000, because you are not going to get them here if they are not interested.

Mr JENKINS —What about the peer group and professional support? Should we be looking at that?

Dr Glasby —That has been addressed by a number of the reviews that have been done in rural situations. You are probably aware of most of that data. Of course, it is a major issue, not just for us, but also for the health workers in those places where we are working. You will be visiting them, and you have probably visited other Aboriginal communities. The status of Aboriginal health workers in those communities is unfortunately low. We rely on them as core health people to be able to interpret the situations that we are working in. All of the doctors working in those situations look at

how we can improve that situation. But it is caught up in the whole issue of their training, their situation, their inabilities, the barriers to their being able to come to work, and all of the other issues and situations which have been well documented and written about.

All I can say is that all the GPs working in the Top End are all committed, as sensible people, to working towards a solution to involving Aboriginal health workers in our work. The Top End Primary Health Care Network struggles—and I emphasise `struggles'—with the issue of how we involve health workers, not just in the daily work, which they actually do very well, but in developing a professional body, which they do not have, and in being able to design their own ongoing learning programs. Essentially, this has all been under the Territory Health Services' umbrella. Although they have done some important things with career structure in the near past, it has not really gone far enough to improve the situation of health workers' participation in the workplace.

Mr JENKINS —Could you tell us what took over from the health care network? What has happened now?

Dr Glasby —When I was managing it I was only doing it for six months while we were tying up the ends to get the next submission approved or otherwise under the divisions program. In that six months the divisions program went to outcomes based funding and all of the previous submissions for funding were then wiped away, and each individual division had to decide what it was going to go ahead with. That was being finalised at a time when the Daly River flood happened. We could have possibly jumped back in on the bandwagon and really pushed this as a divisional issue but it got a little bit subsumed under trying to get some handle on the issue of outcomes based funding from a divisional perspective. What that meant for us as a division was a decision as to which things we were going to run with or not.

I have not highlighted yet the whole issue about how trying to respond to these kinds of requests for information from individuals and small organisations is incredibly difficult. The fact that you have got responses from a couple of GPs separate from any organisations in the Top End reflects the degree of importance which GPs have placed on Commonwealth understanding of the situation from our perspective as workers at the coalface. But we are just not resourced to respond to these things in a really comprehensive and clear way which can make recommendations based on the information as we see it.

The Menzies paper is a very erudite piece of information, but it does not include much information that you would get from people working at the coalface like the Harrisons and the Niemanns and so on. They are not interested in involving us at research at the coalface, because it is too difficult for them and partly because the funding arrangements for our positions are caught up in a whole maelstrom of other conflicting arrangements. So there are huge barriers for them in trying to fund us or to try and work out arrangements with us—let alone the problem of communities understanding the

documentation of how things work. We are not talking about high-powered research at the community level; we are talking about action research type stuff, which is going on in all other indigenous situations internationally and seems to be getting a bit of a backdoor step here.

Mr JENKINS —I do not want to deflect from that action research, because I know that Allan will probably want to continue it, but I am desperately interested in completing this division question. What have they funded now?

CHAIR —In other words, is there a need for this Top End primary health service network or not? There was when you were involved in it. Obviously, things may have changed now and it is not and there is something else in place. That is how I want you to answer it.

Dr Glasby —Territory Health Services have such an inadequate response to human resource management that they are struggling with the idea of trying to support their multi-disciplinary teams. In the Katherine region they have just created a position—and I wonder where the money came from for that if it did not come from coordinated care trials—to have a remote health services manager to try to coordinate health workers and nurses in the health centres that are out bush. This is another level of bureaucracy that has been added because the health worker managers do not work and the nursing managers do not work properly with the team, so they just throw in another level of bureaucracy.

This is the Territory Health Services' response to a problem. Rather than getting good management in, they add another level of bureaucracy. Yes, we do need support, we need facilitation, we need decent management. I believe the only answer to that is to have decently funded regional health services which provide Aboriginal controlled services of that nature. If you have got Territory Health Services running things, it is not going to happen, I do not think. That is trying to work constructively within a very difficult situation for the Territory Health Services. They are operating under very difficult circumstances, and they are immature and under-resourced. Look at the data that has come out of the Territory Health Services to try and justify the funding that they are applying. They have got morbidity stuff from the hospitals but, in terms of what is coming out of the health centres, we have got nurses and health workers generating data every day which Territory Health Services cannot actually analyse or feed back to them.

CHAIR —Let alone make available to us.

Dr Glasby —Does that answer your question?

Mr JENKINS —Yes, it does.

Dr Glasby —Yes, this is an important issue of facilitating multi-disciplinary teams. The division took it up because we were GPs struggling with working in these situations.

It needs to be done in a much more concerted way with the Commonwealth taking control of the situation and working towards something that is much more sensible.

Mr JENKINS —And the regional approach could also cross the state-territory boundaries which can be a problem?

Dr Glasby —People have looked at a sort of Top End, Western Australia, Queensland, Territory type of approach, but I have barely enough expertise to respond to your request for submissions but, beyond that, I really could not comment.

Mr JENKINS —I am not sure how Hansard could handle the gesture with which you answered that question so well. The body language said it all.

Mr ALLAN MORRIS —`He gently raised his hands in despair' would be the way you would describe it I think. Dr Glasby, with regard to that action research you mentioned. I guess I was trying to talk to Professor Mathews about the idea of GPs being not high-powered PhD students but people who are trying, by their own work, to improve the medical circumstances of the country—and how that had to be part of some other accreditation process and part of a broader program, not just mickey mouse. It had to be owned by the community so they agreed with it, and it had to be complementary to what they were doing in terms of their service provision.

Dr Glasby —Yes.

Mr ALLAN MORRIS —You called it `action research', which I thought was a good phrase to use. You have a better picture of it than I have.

Dr Glasby —I am not sure about that.

Mr ALLAN MORRIS —Can you draw that picture a little bit?

Dr Glasby —Action research is a fairly simply concept, but basically when you are working in pioneering situations there is not a lot of data to support any one action over another and you are stuck with either doing something or not doing something. Most people who are out there are gutsy enough to do something but you have to have the resources to look at the effects of what you have done. So you have an action and you research that action and you come up with, `Well, okay, that has or has not been very effective' at a local level.

Mr ALLAN MORRIS —How do you make that part of a broader picture? In terms of the action research you might do in one community with a diabetes case or with a particular heart condition vis-a-vis another doctor in another community with another case which may end up being of a similar nature, how would you actually relate those within a framework?

Dr Glasby —Action research is about publishing small-time information. It is coalface stuff. It is all based on `When we had this, we did this and this happened', so that somebody else, as you have mentioned, in the next community can say, `I can see what you are doing and that is really practical'. It is a practically based approach to research at the coalface.

Mr ALLAN MORRIS —What kind of framework could help do that? Would it be a CRC, a university or a hospital? How could you actually develop a framework where that was known, recognised and accredited so that the person eventually achieved some professional status, standing or recognition for that work they were doing?

Dr Glasby —It has to come back to the community's participation. That involves a certain amount of commitment to resourcing and training of local people to be able to understand this stuff.

Mr ALLAN MORRIS —I am with you there. So assume the money is available, assume the Commonwealth will provide X dollars to deal with it: who would it channel through? It cannot come to the person direct, because they are just at the bottom end of it.

Dr Glasby —That's right.

Mr ALLAN MORRIS —It has to come through some intermediary.

Dr Glasby —Yes, regional health boards.

Mr ALLAN MORRIS —You just told us that it was not through the Territory Health Services.

Dr Glasby —Exactly. That is right—not the Territory Health Services. They do not have any regional boards. They do not have any health boards whatsoever. They have not managed to generate any. I am not sure about the Tiwi Health Board. Do they get supported by THS at all?

Dr Harrison —Yes.

Dr Glasby —Grant in aid—but did it support the Tiwi Health Board?

Dr Harrison — Yes.

Dr Glasby —That would be the only situation where it was able to. Regional health boards have been only Commonwealth initiatives.

Mr ALLAN MORRIS —I am looking at professional status to ensure that we are looking at both the financial support for the people doing action research but also the

professional support so they are recognised and not simply GPs working under primitive conditions—not people who are out of touch with their peers but actually at the front end of medical development who are doing work which is far beyond the work of a normal GP and, what is more, is being understood and recognised.

Dr Glasby —The CRC we have here within Menzies is a potential venue for that type of activity. I am a little concerned about the consultation process between a high-powered research organisation like Menzies and people at the coalface. It is not always creative.

Mr ALLAN MORRIS —So the division of GPs has been the intermediary?

Dr Glasby —The division of GPs has got its own problems, but at this stage it would probably be the most useful forum for channelling this kind of activity and resourcing these kinds of activities.

Mr QUICK —I want to ask about something completely different. You might be aware that we did a report on telemedicine. I am interested in your comments on page 3:

Our local health department . . . has a timetable to implement their rural remote IT in health program. We cannot call it an upgrade as there has never been a primary program . . .

Can you expand a little on that?

Dr Glasby —Territory Health Services have just completed the urban second upgrade, so all health services, and, more importantly, all the bureaucrats sitting in the offices in town, are now up to Pentiums and the whiz-bang things on their desks. The clinics out bush have usually got a stand-alone computer which has a few games on it and Word—something for them to gain some skills on. They have had this IT program going now for several years, and the program that was being written for bush communities was subsumed under the coordinated care trial and has now become bigger than Ben Hur's horses and has taken another six months to a year to get it to the stage where it was going to be last year. It is the whole issue of lack of prioritisation. From my perspective of working at the coalface, we have got nurses and health workers working in clinics out in the bush who are not being resourced to a basic level of functioning that people in town would assume as being natural. This disparity between the second upgrade occurring to systems in town when they have not even got a system out bush only highlights again this issue of the prioritisation of health issues at a rural and remote level versus what is happening in town.

We are dealing with a very small population in the Territory, and that is why we have got such a big percentage of health moneys being taken into the bureaucracies. I believe it is bigger than any of the other states: 54 per cent is the stated figure of moneys being withdrawn from any service delivery funding from the Commonwealth. The Territory Health Service takes that off the top as part of maintaining the bureaucracy,

which they have to do with such a small situation. We need to be able to make it leaner and meaner because the services are not going bush. I believe the Commonwealth provides, through the working model of regional health centres, this kind of possibility.

There was one point I would not like you to gloss over. It is an issue you have also addressed, Mr Morris, of standards out bush. This is another area which needs lot of resourcing from the funding bodies. Most other health centres in the country have got some kind of accreditation program running within their doors. Territory Health Services are working towards it but, because of the situation, again there are no standards that can be applied. In fact, we do not even have procedures manuals for nurses to operate in terms of how clinics are managed out bush. We have procedures manuals for how to manage conditions but we do not have procedures manuals for how to deal with a specific situation of human resource management, personal trauma in the workplace or dealing with the community issues. Those kinds of policy and procedure manuals do not exist. This would only highlight the immaturity and the lack of resourcing for bush clinics that is operating under our current situation.

Mr ALLAN MORRIS —I would go further. In the wider community there is a view about Aboriginal health as a separate entity. At one end of the spectrum it is a massive waste of money and allows a great waste of resources. At the other end of the spectrum it allows us to accept a level of health that we would not accept in any other Western society. Those two views are argued, and that differentiation in some ways allows us to accept a standard of health which we would not tolerate in Sydney, Melbourne or Newcastle.

I do not quite know how we handle that. I think we are looking to people like you who are working as professionals in the field to make it understood by those of us who are not professionals in your field that the levels of health that are actually accepted as acceptable in remote and outlying areas are just disgraceful.

Dr Glasby —I think it only highlights the issue that, if you put money into things, it does not necessarily work—and that is separate from the fact that I am not sure whether you are talking about money into Aboriginal health or money into Aboriginal situations.

Mr ALLAN MORRIS —People say that all this money has been spent on health—in fact look at our last term of reference—and Aboriginal people are actually sicker; they have more renal failure and more diabetes. So one argument that is put to us is that it has all been wasted. The other argument that comes forward to us, particularly from the Aboriginal community, is that by having it separate, you actually allow a second-class treatment—and we do. Both are argued. I am more inclined to the former—in the sense of allowing a second-class standard—but yet all the doctors are of the same standard. Doctors in Sydney and Melbourne and in Aboriginal communities have all been through the same medical schools and have the same professional status. So, in a sense, the profession itself allows us as a community to accept substandard treatment.

Dr Glasby —It is not quite as simple as that. It is not substandard treatment; it is the participation of people in their health service because it is not their health service. I do not believe that what you are talking about as two things are actually two things. The fact that there has been a lot of money—

Mr ALLAN MORRIS —Two extremes in a spectrum.

Dr Glasby —I do not see them as opposite ends of the spectrum. Just because you put a lot of money into something does not mean that you necessarily get a lot of outcomes out of it.

Mr ALLAN MORRIS —I agree.

Dr Glasby —The fact that you have substandard treatment or substandard health outcomes has no relation to the fact that you have put a lot of money in at the other end. ATSIC held Aboriginal health moneys for a number of years, and I believe was inadequately supported to actually take on that role—but that is a separate issue. We now have a situation of there never having been adequate resourcing of Aboriginal health—never—and we are now having to respond to the international situation where this is unacceptable. People of Australia accept, by and large, that it is unacceptable, but the solutions have not been there.

Mr ALLAN MORRIS —I should have said `two competing perceptions'. That would have been a better way of defining it. But the professionals who work in the field are the same.

Dr Glasby —Yes, but how can you have health of a people who are not interested in going to a health centre? There are issues why people will not go to a health centre. You understand that, don't you?

Mr ALLAN MORRIS —They are the same health centres that took away children.

Dr Glasby —That is an issue, but it may not be quite as important as it used to be. One has to understand—and it is not easy to discuss this—that Aboriginal people have a lot of other health options than a health centre. It has been well documented that Aboriginal people will search for other options for health care before they will go to the health centre generally—not unlike a lot of non-Aboriginal people.

Mr ALLAN MORRIS —Yes.

Dr Glasby —The fact that money has been poured in there does not mean that the second-class quality of health care is because there is not enough money; it is because the approach is the problem. This is where the whole issue of community

care, of which I am only another component—

Mr ALLAN MORRIS —Then what you are really saying is that unless Aboriginal communities approach health the way we want them to approach it—

Dr Glasby —No, I am not saying that; I am saying in the way that they want to approach it, which has not been addressed.

Mr ALLAN MORRIS —Their level of health medically is vastly lower than that of a non-Aboriginal community—massively lower.

Dr Glasby —Yes.

Mr ALLAN MORRIS —Part of the reason for that is because they do not approach health centres.

Dr Glasby —Yes.

Mr ALLAN MORRIS —We say that they must fit the centre, but a survey in 1988-89 found that 80 per cent of students at the medical faculty of Brisbane university believed that the health conditions of Aboriginals were their own fault. This is a similar perception. We have to be careful that the system should fit the people who need it. In other words, the medical centre should be relevant to the Aboriginal community. The doctors who practise in those centres practise medicine in Melbourne and Sydney in the Turkish community, the Greek community and the Italian community and they make it adaptable there. But we have not adapted it to the Aboriginal community somehow.

Dr Glasby —Doctors perform in those communities at a level not dissimilar to other places. I do not see the issue of a doctor's work as being necessarily related to the health outcome. That is separate from the fact that we have not had doctors in most bush communities. But health outcomes, we know, are not related to medical care by and large. As was very succinctly pointed out by Allan Walker and a number of other submission writers, until you have economic situations in communities so that people are able to work and educational issues are addressed by the community, you are not going to have health improvement. You are saying: `Because you have good doctors there, why don't you have the same kind of health that you have in other places?' This is a complex, multifactoral situation.

Mr ALLAN MORRIS —I watched Dr Leed campaign for money for research for AIDS and for other major medical crises. I do not see the same kind of thing happening in terms of the crisis in Aboriginal health.

Dr Glasby —There are significant Aboriginal directors of organisations in the Territory. We need to be subservient. One has to understand this from a community control perspective. If a doctor stands up and says too much, then it is calling too much on yourself. We can respond to the situations we work in and numbers of doctors do.

Mr ALLAN MORRIS —That's a fair point.

Mr QUICK —The minister in his speech mentioned that Territory Health Services has established the Aboriginal health strategy unit, which according to him functions much as the recommended task force would. The Aboriginal health strategy unit spearheads the strategic direction of the department to ensure there is measurable and sustainable

improvement in the health of Aboriginal Territorians.

Dr Glasby —Yes.

Mr QUICK —How is the Aboriginal health strategy unit working? Is it effective? Has it just started work?

Dr Glasby —You have been a politician for a long time, Sir.

Mr QUICK —No, not all that long.

Dr Glasby —I would only interpret that as politico-speak.

Mr QUICK —It says here:

The unit is a discrete division of TATS, with the assistant secretary reporting directly to the secretary as a member of the TATS executive. It is a small but focused unit comprising of two senior policy officers; one project support officer; one administrative assistant; three project officers working on three key projects, namely the Aboriginal Employment Strategy, interpreter and translators trials at Royal Darwin Hospital and remote area environmental health standards. . . Of the nine staff members, six are Aboriginal, including the assistant secretary.

So it all sounds wonderful.

Dr Glasby —It does.

Mr QUICK —But it is not working.

Dr Glasby —What can you do with six or nine people to address the resourcing required for community control? In the Katherine West health border I can only speak of the situation I am in at the moment. A year of training has gone into our Aboriginal health board to make them active as community representatives making decisions on health matters as to their region. It has required an external source of funding and commitment to that as a priority for that to happen. You know the numbers involved in the coordinator care trials.

Territory Health Services are moving in the right direction. I have continued to affirm that and I believe that I am trying to be positive about the situation. But the Territory is a very small place, and it is still immature in terms of its development of policies and so on. It takes a long time, as you are well aware, for government activities to

actually be active in the field. Who knows what might happen in 10 years if it was left alone? But it is not going to be adequate to the task ahead of it because it is so large. It is a national problem, not just a Territory problem.

Mr QUICK —Could I have your views on the patient assisted travel scheme, which assists people in remote areas to access outpatient clinics in hospital care?

Dr Glasby —Certainly. A number of your other submission writers have actually commented on this far more sensibly than I have. I made a small comment in the third paragraph on page 3. The patient travel scheme attempts to bring people in to access mainstream services. Most of the Aboriginal people coming in on those services are unfamiliar with life outside their community. Let me qualify that. You will understand the example of, say, a shy 20-year-old woman. She may be a single woman or she may have children, but she is a shy woman, and she has always lived in a small community situation with lots of her family around her; yet you want to put this woman on a plane—by herself, potentially—and say, `Go to Darwin hospital with these other people.'

I can show you Aboriginal women of 20 years of age who, in a semi-urban situation such as in Katherine, even, where there are lots of other Aboriginal people around—let alone in Darwin, where there are a lot fewer—would operate essentially as a 12- or 13-year old would operate. This is not at all to diminish them: this is just the kind of interaction that we are talking about understanding; yet we are constrained in our patient travel scheme by the fact that anybody over a certain age cannot be escorted—and that also goes for shy men, and they exist in large numbers.

CHAIR —You mean that they are not funded to be escorted, don't you?

Dr Glasby —That is correct. I am sorry. In a sense, the scheme is inadequate to the cultural situation. Again, I would point to the Mike Dawson and Margaret Niemann submission, which spent quite a bit of time outlining the barriers associated with the appropriate use of the patient travel scheme. You will get a lot more depth out of their response.

Mr QUICK —After listening to your last comments I wonder if, where the minister says on the topic of resourcing that, over the past three years, Territory Health Services has been taking a `leading role in Australia in introducing an economic approach to decision-making and resource allocation in the health sector', that is a case of `enough said'.

Dr Glasby —Enough said!

Mr QUICK —No further questions from me, Mr Chairman.

CHAIR —Dr Glasby, we have been here since 8.30 a.m., and we might actually

catch up with you again later in the week, I believe.

Mr ALLAN MORRIS —Dr Glasby, when you read the Hansard , you will have a lot of hindsight, and so you can write to us and tell us about all of the things you think you should have said. We are happy to get more material and more ideas. You were very self-effacing in your submission. You do not need to be. We think you probably have more answers than we have. I encourage you to perhaps ponder on it beyond today.

Dr Glasby —Okay. Thank you very much.

CHAIR —We will see you on Wednesday morning: is that right?

Dr Glasby —I am not sure whether I will be at that meeting.

CHAIR —All right. We will see your facility, anyway. Thanks very much. I enjoyed your evidence. It has been very good. It is good to get it from someone who is in at the coalface and has made the commitment to be at the coalface. Thank you very much, Michael. The committee stands adjourned, with grateful thanks to everybody who has given evidence today and to Hansard . Thank you, Susan and Jason, and thank you, Bjarne.

Resolved (on motion by Mr Quick , seconded by Mr Allan Morris ):

That, pursuant to the power conferred by section 2(2) of the Parliamentary Papers Act 1908, this committee authorises publication of the evidence given before it at public hearing this day.

Committee adjourned at 4.29 p.m.