MIEGEL, Mr Fred, Clinical Nurse Manager, Territory Palliative Care, Central Australia, Northern Territory Department of Health

[10:01]

CHAIR: Welcome. I understand information on parliamentary privilege and the protection of witnesses and evidence has been provided to you.

Mr Miegel : Yes, thank you.

CHAIR: I would like to invite you to make an opening statement, and then we will ask you some questions.

Mr Miegel : Thank you for this opportunity. I have been working in this position, off and on, for about 17 years now. In the Northern Territory there are two palliative care services. One is the Top End service, which covers Darwin and the greater region, the islands off the Top End and down to Katherine and Lajamanu. Here in Central Australia we cover from Elliott, just below Katherine, over to the Queensland border, down into the Pitjantjatjara lands of South Australia and to the Ngaanyatjarra and Yankunytjatjara lands of Western Australia. We work very closely with some of those organisations that Sarah mentioned, such as Nganampa Health from South Australia and Ngaanyatjarra Health from Western Australia. It is an area of about a million square kilometres—bigger than Texas—with a population of roughly 50,000 people.

The service here in Central Australia comprises six positions. Five of those are filled at the moment. We have a palliative care consultant who commenced in January this year and two nursing positions—my position and another nursing position. There is a social worker position, an admin officer and an Aboriginal health worker position, which is vacant at the moment. As was mentioned by Sarah, and I am sure by Dr Boffa and Donna Ah Chee, health workers are very hard to get hold of and to recruit. Of course, death is a very sensitive area for Aboriginal people, so to work in that sort of area as an Aboriginal person is very delicate. So we are trying to find somebody who is willing to take on that role.

I have a small number of statistics which I have collected over the previous 12 months. Of the population in the Northern Territory, as stated by the ABS, roughly 39 per cent is Aboriginal. Here in Central Australia it is probably much higher than that. Within the palliative care service, in the 12 months from July 2010 to June 2011 we were involved with 210 clients and 70 per cent of them were Aboriginal, with the majority of them here in Alice Springs, a large proportion from remote areas, Tennant Creek, and then transient people—grey nomads who are doing a final trip around Australia. Those sorts of cases come across as well. Most palliative care services see a large proportion of cancer cases because that palliative has grown out of cancer care. Here in Central Australia in that period we saw fewer than 40 per cent of malignancies. A quarter of our clients were end-stage renal patients and other chronic diseases made up a large proportion—lung disease, cardiac disease, liver disease made up the rest. Mirroring the number of clients, 66 per cent of our deaths were Aboriginal. Place of death: 60 per cent of our clients who died, died in Alice Springs Hospital. In that time 106 people died. Other institutions: 10 to 12 per cent in nursing homes, 10 per cent in remote communities and eight per cent in Tennant Creek Hospital. So there were a high proportion of institutional deaths either in nursing homes or in hospitals.

If you are interested in some reading on issues for Aboriginal people, especially from more traditional areas, Richard Trudgen book Why warriors lay down and die would give you a very good incite. There is also another book by Eckert and some other authors calledBinan Goonj, which talks about kinship relationships. John Condon has done a work called Cancer incidence and mortality, Northern Territory, 1991 to 2001, which is available. Chronic disease is a large part of our work, as is renal. The work Sarah talked about with renal dialysis is great work. It is really a joy to work with organisations like Western Desert and Tangentyere aged care, the FAD team which has already been mentioned. The networking to help look after these people is a lot of work. I really take my hat off to those organisations. NPY Women's Council and carer respite hold respite carer funding through the Commonwealth government.

I have noticed that some of your questions this morning revolve around organising for people to die on country. That is an issue. I am sure you have questions about that. Some of the issues we struggle with are bereavement follow-up for Aboriginal people here and compounded grief. We just do not know how to deal with that. We have wonderful whitefella theories but how do we apply them within this cultural context for Aboriginal people. Also in the Top End there is a population with the Machado-Joseph syndrome, which is an ataxia. The Machado-Joseph syndrome website would be worth looking at. It is like a motor neurone disease, just to give you an idea, but it is in a very specific population coming out of the islands up there. There are a few cases here in Central Australia through links in that way and I would like to highlight that for special groups.

Senator MOORE: Mr Miegel, how exactly does your service work? Does it operate out of the hospital? How do you and your extraordinarily small team get a referral?

Mr Miegel : Our service sits at the Community Health Centre on Flynn Drive here in Alice Springs. It is right next to the renal dialysis unit—the major unit. Historically, it was managed out of there. There was a restructure of the department in about 2005, I think, which then brought us under acute care, so our management stream moved over to the hospital—we are managed out of the hospital but we sit at community health. Our focus has always been trying to focus on the greater population. Probably our biggest referral source is Alice Springs Hospital. Our referrals come also from GPs, remote area clinics and other tertiary centres. When people go to Adelaide for treatment, we will get referrals from there and the service then tries to link in with the primary care service. Being a small team, we cannot provide hands-on care. That will always go back to the primary care providers. We link in with each CACP provider and work as holistically as we can—networking with carer respite and the NPY Women's Council to try to get support for families and offering specialist advice to the services that are offering the primary health care.

Senator MOORE: As you may have heard, one of the issues we have had in the committee is the coordination aspect—when a person and a family is going through the decision-making process and, as they work through the coordination element, how to involve everybody who needs to be involved. Is it part of your job—not yours personally, but the unit's—to be the specialists in palliative care, so that it falls to your team to ensure that GPs, health workers, family and community leaders—whoever should be involved, case-by-case—get involved?

Mr Miegel : Yes. It is case-by-case and who is leading the care for that person. We have a really good core GP group in this town who want to do that sort of work, but we have other GPs who really do not want to be involved. That is fair enough—I mean, there are apples and pears here in what is being offered. Within the hospital, we try to use the services they have available. If the patient is on a certain ward, we try to use the social workers who may be on that ward and the discharge plan coordinates that. We try to work with the people who are on the ground already and have the contacts for other organisations. It depends on who is in place to make those decisions at the best time. We have to prioritise palliative care beds in the hospital. Quite often we will have five or six patients scattered through the hospital—in the renal unit, in the surgical unit and in the medical units. We try to work with who is there to coordinate, not to take away other people's jobs. We do not want to take over their roles. As a specialist unit we are there to consultant and to support. Seeing 200 people with very complex needs over a 12-month period is a big ask.

Sarah mentioned that renal patients will often have diabetes. If they have been on dialysis for more than five years they will have the cardiac problems that go with the disease. They can start to get bone breakdown from the leaching of calcium out of the system, so the osteoporosis type syndrome is there as well. Just because their kidneys fail does not mean they do not get cancers of other areas. We have looked after quite a few people who have been on dialysis for quite a period and then develop a cancer.

Senator MOORE: So if you are not providing the treatment are you more, in medical terms, the case managers?

Mr Miegel : I am a bit wary of taking on the role of case manager, mainly because we do not want to take over. We do not see ourselves as able to manage all the clients that we get on our books. As Dr Boffa mentioned, there are different levels of care that we would be involved in. We do a lot of consulting at the nursing homes. Sometimes that can be just about being there for a family meeting to maybe advise where things are going. We might be involved because a dementia patient has got to the stage where they cannot eat or drink anymore and the family are pushing for further treatment such as a PEG tube to be inserted. We not only explain the risks of a PEG tube but also explain that, with dementia, part of the disease process is that people do forget to eat and drink. It is part of the dying process. It is a natural part of that process. Sometimes we play devil's advocate and say: would this person want to live longer with a tube in their stomach? Then the family needs to make that decision. But they need the information and part of our role is to ensure that people have the information to make those decisions.

Senator MOORE: One of the ongoing issues in the inquiry has been people's concern that there is not a one-stop shop, that through the whole process of getting the support you need, no-one seems to have the answers you need. You have to research it all yourself over and over again. That plaintive cry has, I think, come out in every hearing we have had. People have mentioned that.

You talked about the PEG feed situation, which is a standard process. It ensures that people have the support to use the PEG feed tube, to clean it and to not panic when things go wrong. From your perspective, in your services, is that the kind of thing you do with the person and their family to ensure that that is there or does that responsibility belong to their medical practitioner? I do not know what the community nursing service is like in Alice. Once someone has been referred to your service, can you, and particularly your social worker—I am pleased to hear that there is a social work service in the unit; God bless them and I hope they have a lot of people working with them as well—work with the family to ensure that through all those steps they know what is going on?

Mr Miegel : Again, I come back to the fact that it is very situational. The reality is that, with six staff, we cannot do it for everybody. But at different levels there are occasions where we do have to step in and do that. That is part of the negotiation process with the GPs, with who is providing the care, whether it be a nursing home, an EACH-package provider or Tangentyere Aged Care. I wish I could say that I do more education, but time does not permit us to do that. It is about liaising with these teams and the appropriate people to deliver that education. It might not be appropriate for me as a male to be trying to teach an Aboriginal woman about a PEG tube. So where do we go for the appropriate people to deal with that? The people who Sarah alluded to are the Aboriginal Liaison Team at Alice Springs Hospital. We depend on them quite a bit in that cultural negotiation sort of work. When we get a referral we go in and we will do an assessment. We will try to then work with the teams that are already there and help them out with what is going on, whether it be the FAD team or whether it be in the hospital. We find out what teams are there and what extra services we can pull in. We negotiate care and try to work through the minefield of getting people back to country—the travel, who will look after those people and is it more than a one-nurse clinic post?

We have had a story of a fellow who died about 200 kilometres north of here in a community, and all he wanted to do was stay in the creek bed the whole time. It took us probably two months to get the nurses to say: 'It's okay. That's what he wants. This is his choice.' We worked on them and finally it clicked for them and they were able to say, 'Yes, this is what he wants, and that's okay.' Trying to give people choice is very important. The hard thing is when people get stranded in the hospital. Family are not able to or will not look after them at home. God bless organisations like the Yuendumu Old People's Program. We had a fellow who died out there last week. We were able to visit, do some negotiation, take some medication out with us, set them up and have a phone call available—we offer a 24-hour nursing-on-call service so that we can talk through the issues at any time. I have been rung at midnight by remote nurses saying: 'Fred, what do I do here? Where do I go with this?' The decisions can be talked through. At the end of the day, these are the people on the ground who have to make the decisions and they have to live with those decisions.

Senator MOORE: So the six-person unit also maintains the 24-hour telephone service?

Mr Miegel : Two of the six, yes.

CHAIR: The two nurses?

Mr Miegel : Yes.

Senator MOORE: You are a Northern Territory public servant; is that right?

Mr Miegel : That is correct.

Senator MOORE: Okay, so we will not ask you questions that you cannot answer because of your position. Is the funding that comes to your unit determined by the state government?

Mr Miegel : The Territory government.

Senator MOORE: Yes. The Territory government makes it and that is from the federal funding. They make the decision and then is it allocated to you on an annual basis?

Mr Miegel : Yes. That is my understanding.

Senator MOORE: So it comes through on an annual basis. Are you given an expectation of what services your unit is to provide?

Mr Miegel : Yes.

Senator MOORE: The 24-hour nursing, the coordination, the referrals—all that is identified?

Mr Miegel : Yes.

Senator MOORE: We can make the statement—you can't—that it does seem to be inadequate in terms of the needs of the region. Because of the particular nature of the areas that you have described, do you get support through the South Australian and Western Australian governments as well?

Mr Miegel : I could not answer that. I know there are tri-state agreements.

Senator MOORE: Both Senator Smith and Senator Siewert are Western Australians. I am from Queensland and I think you would not be doing too much across our border, but, with Western Australia and South Australia, because of the Alice network, you may well be, so that is something we will have to follow up.

CHAIR: I am conscious of what happened with dialysis and the issue that we are not taking any patients from WA and South Australia because of funding.

Senator MOORE: That is very true, so we will follow that up. Do you have links with palliative care units in those states? Is there a kind of palliative care network of people who work in those quite specialised areas? You said that you have been here for over 12 years.

Mr Miegel : This is my 17th year here. We have always had really good support from the Royal Adelaide Hospital. That has been our tertiary cancer centre up until the last couple of years, when the Alan Walker centre started up in Darwin—the radiation oncology unit up there. So we have always had good support from the palliative care service and the oncology service from down there. Patients with private funding sometimes explore organisations like Peter MacCallum for their cancer treatment and things like that. But also they will go back to where their power base comes from. Alice Springs is a transient place. If somebody gets a cancer and they are not long here from Brisbane or Sydney, they will go back to where they know the services. That is part of living in Alice Springs. We have a very close relationship with the Top End service because we are under the same sort of management stream.

Senator MOORE: Have they got a similar structure?

Mr Miegel : They have a 12-bed hospice up in Darwin. They have a community section and the hospice. One of the reasons, I understand, that we come under acute care is that the hospice sits on the Royal Darwin Hospital grounds and it was easier to just manage everybody out of acute care.

Senator MOORE: Fair enough. Do they have that kind of structure that you described, where they have a GP specialist, specialist nurses, an admin person and a social worker? Is that a similar network?

Mr Miegel : Yes. They also have access to a dietician, a music therapist, a pastoral care worker and an OT.

Senator MOORE: Is that because of the larger size of Darwin—that there are more people?

Mr Miegel : Yes. It is three or four times of the size of the population that we cover here. They have the population base to justify it. Here it is a bit harder. As I said, we network as much as possible and use the services out the hospital and the organisations that we work with.

Senator MOORE: I noted your response when the advanced care director question was being asked and I know that is a particular passion of Senator Siewert's, so I will leave the questioning to her on that. But I did note your response in terms of the hospice issue. It did come up with some earlier witnesses. From your professional perspective in Alice Springs, is there a case for having a hospice here, amongst the other priorities?

Mr Miegel : There is a case for something and I am not sure what it is.

Senator MOORE: Sure. I understand that totally.

Mr Miegel : It was really interesting to hear Sarah talking about that. Over the years I have had thoughts about accommodation. Accommodation is a huge issue.

Senator MOORE: In every area in this town.

Mr Miegel : It is. That is something that we are working on. I am not sure what I can say about that at the moment. We did have a submission in to the last budget for a sub-acute facility here in Alice Springs but unfortunately I think it missed out. It would have had some dedicated palliative care beds but unfortunately that is not happening.

Senator MOORE: But, in terms of community need, it could well be something that would continue to be on the agenda for funding. It is just at the moment that you do not have the funding for it.

Mr Miegel : There is something in the works there but I do not think I am at liberty to say—

Senator MOORE: It is just at this stage you cannot—

Mr Miegel : Yes.

Senator MOORE: That is fine.

CHAIR: Can we talk about advanced care.

Mr Miegel : Let's talk about advanced care plans.

CHAIR: How much are you involved with that process and/or, if you are not, how much are you aware of that actually happens?

Mr Miegel : At the moment in the Northern Territory we do not have a medical power of attorney, which in a way hampers some of the advanced care directive capabilities of who can then take that power of attorney. We have a financial power of attorney but not a medical one. That is on the agenda to be changed. I understand that there is legislation, which I thought was going to go through in May, but it has been held off, probably until September.

CHAIR: Yes.

Senator MOORE: One of the commitments out of the COAG is that the NT has made a commitment there.

Mr Miegel : Right, so that legislation is being worked on. That leaves us a bit in limbo. There is legislation from 1988, the Natural Death Act, which is a very simple, one-page sheet. That is the legal documentation, but it does not hamper the discussion, and that is the important thing. From a palliative care service point of view, we are advocates for advanced care planning. The problem is having a discussion about death, especially with Aboriginal people, is a culturally touchy thing. Renal did try to take steps to start dealing with this, and I think every chronic disease really needs to start, maybe at diagnosis, having these discussions, but unfortunately it is a very hard discussion to have. There is so much going on and if you start to talk about death in the middle of treatment it can be misinterpreted. I know the renal team did find it hard it here because if they started talking about death to everybody when they come into clinic they would have nobody turning up to clinic. It is a catch-22 in some ways.

For the palliative care team, I have always advocated that it should be the primary care team that has these discussions. It is not good having a death team coming in to talk about dying. That is going to put people offside automatically. But if a primary care person has trust, has a relationship with that person, they can start to open those discussions, and I think it is very important, as Sarah said, that it is not a one-off discussion. It has to be a continuous discussion. Saying that, we have had some really good district medical officers working out in remote areas where they have actually sat down with family members and have had 15 family members sign an advanced care directive written by somebody. The problem with that is that, if you miss one person and they start to make waves, there can be implications of payback and there can be implications of retribution for that. So sometimes we end up with people in hospitals who should never be there, but unfortunately—

CHAIR: No-one has been able to agree.

Mr Miegel : That is right. The person says, 'I want this done,' and the other 15 people say, 'Okay; we won't be held responsible for that.' So it is a delicate thing.

CHAIR: Where that has occurred—for example, where a range of family members have signed on—is that when the patient has actually articulated their wishes?

Mr Miegel : Yes.

CHAIR: So the patient may articulate their wishes and, unless the family agree, it is no go.

Mr Miegel : Yes. It can be quite complicated. We had a lady die in the hospital here about two months ago. She was born in one community but was one of the first families to move to another community that was set up. When it was quite obvious she had a terminal disease and she was going to die she was torn about where she wanted to be. In the end, she said to us, 'I can't die in this place or this place; I would like to visit.' We tried to do that, but unfortunately her disease progressed in such a way that we could not do that. Then there was family infighting about where she would be buried. She said, 'I want to be buried in this place,' and the family from the other place started threatening the family from that place. So she rescinded and said, 'I'll leave it to you; it's too hard.' It is complex.

Family is such a big thing in Aboriginal communities. I heard Donna and Dr Boffa respond about houses being left empty. What we have done is got people to build bough shelters away from the community, and that has worked sometimes. We meet many different obstacles trying to get people back to communities. If it is a single nurse post it is really unfair on that single nurse to put the person there. The family have to understand that the nurse cannot be at their beck and call 24 hours a day, unfortunately. If they want this person back, a lot of negotiation goes with that.

CHAIR: Do you think that there should be a broader discussion in the broader community—we found this in other communities; it is not just an issue in Aboriginal communities—about what advanced care directives are, to expand that discussion? Obviously it would be a different discussion than in other communities. Would that help?

Mr Miegel : I think it would. The problem is that we are sitting in an area where there are about 17 different language groups and dialects. We are dealing with a culture here. I am being specific to Aboriginal culture here. We are dealing with very traditional people and very urbanised people, and there is a real gamut in between. They are probably starting to use media, the radio, podcasts. I know the Top End have started doing that with some of their palliative care stuff. It would be really helpful slowly getting people to talk about it. I think you are right. It would be. But it is time consuming to do the breakdown of having those conversations. There is a bit of a lag from many years ago about, 'What is your agenda behind this?' That is part of it as well. Having those conversations is definitely the only way we can do it.

Senator MOORE: The kinds of things you are talking about with returning to country and all that extra time and even the things we heard earlier about blankets and food, who funds that?

Mr Miegel : We link into NPY Women's Council through their respite funding, carers respite—

Senator MOORE: Existing funding?

Mr Miegel : Yes, where there is existing funding. Sara is great at doing creative accounting, because she can.

Senator MOORE: And because of the network around her.

Mr Miegel : That is right. It is trying to organise that sort of stuff. We have been lucky in that through Palliative Care Australia—

Senator MOORE: The funds that they have.

Mr Miegel : there is funding available. We now have three boxes of blankets sitting in our storeroom. But that is equipment. The everyday stuff, such as incontinence pads for people, we buy out of our budget. There are vinyl covered mattresses that we can send out to people just to sit on their verandas that we know we are not going to get back. That is $80 a pop. We are willing to wear that cost in what we can provide. It is those consumables which—

Senator MOORE: So that is part of your operational budget?

Mr Miegel : Yes.

Senator MOORE: You actually have to have something put aside for those quite specific things which other services elsewhere might not need to do?

Mr Miegel : It is sharing around what we can do—trying to scare up old beds or the visits to the dump shop here even to see if there is an old bed we can send out bush and who can come up with what. It is those sorts of things.

CHAIR: I have two more questions. One is around how much time you can actually spend in communities given your limited resources and the fact that you cover one million square kilometres. How much time do you actually get to be in communities?

Mr Miegel : In remote communities, very little. It is a very ad hoc sort of thing. We try to get to Tennant Creek at least four times a year, but that is sometimes quite a push. Numbers up there can vary from three clients to 10 clients at any one time. If we are lucky, most of them might be having chemo so we might be able to see them when they come down here for chemotherapy. But there is still the education focus that needs to be put out there. We try to link in with the remote area nurses as much as possible and the orientation for the new staff getting out there, just making them aware to ring Alice Springs Hospital. We all have mobile phones and we can be contacted at any time. Like for this gentleman who died earlier in the week, we were able to put in an urgent trip. We have done halfway meets to deliver syringe drivers and drugs to remote area nurses so they can take them back to keep things going for their clients. I must admit that clinics that are close to town—Hermannsburg, Ti Tree, Santa Teresa—within an hour or two hours drive, probably get a really good service from us. It would be much, much better.

CHAIR: Titjikala?

Mr Miegel : Titjikala—yes. And they are the nice things. We quite enjoy getting out and doing that, but, in saying that, it is still time. Travelling time alone to Tea Tree is four hours, so you have lost half a day. Then, if you are taking the doctor with you, that is a consultant out of telephone range as well. There are implications for being out bush in that way. We have some really good things happening, like PEPA. Sue Stewart up in Darwin is the project officer for the renal palliative care project that has been running for about three years. The really good outcome from that is that now there is a dedicated palliative care nurse in both renal teams, in the Top End and in Central Australia. That has made a huge difference for us.

CHAIR: Do they work with you or with the renal unit?

Mr Miegel : They are managed by the renal unit but they link really closely with us. They attend our team meetings. Uli, who is here, attends our team meetings. She is the go-between. Part of the problem with the choice of not having dialysis is that people are not symptomatic. Until they are symptomatic, they do not feel that they are sick. They are told they have had the blood test, but that is just numbers on a piece of paper. Until they feel sick, they say 'What are you talking about? I'm okay.' Quite often you will get people who are at a stage 5 renal failure, which is when they need to start to look at having dialysis, and they are still not symptomatic, and by the time they are symptomatic, unfortunately, it could be too late with what goes on with that. Like Sarah said, the whole gambit of what goes on with people is very complex.

I know that within other states and other palliative care services, they will not take on renal patients until they actually stop dialysis. Here in Central Australia, we also play a symptom control role. The renal team often refers people for pain control advice, because you cannot use morphine with renal patients; you need to look at things like fentanyl and oxycodone and the other drugs you can use that are not going to do more damage or have metabolites sit in the system. It is a consultative sort of role that our team works on as well. Probably, of the 200 people was talking about, 50 of those were referred for consults about pain and other issues, and then they will come off our books again; they will be discharged. We are not a one-stop shop but we will help plug the gaps as well.

CHAIR: One of my questions has made me realise that I forgot to ask another question. It is about carers. Carers have come up time and again during our inquiry. They are absolutely crucial for looking after the person, but there also needs to be support for them. How much of your limited resources and time do you have to be able to support carers versus the actual patient?

Mr Miegel : Our social worker does a great job. We try to use social workers who are in situ—that is, in hospital with the renal team, but community social workers as well. We try to get her to coordinate supports. There is also carers' respite. Frontier Services offer a carers' support person. They are dedicated and we will refer people quite often. Here in Alice Springs, if somebody is going to die at home, the community nurses and the palliative care nurses, if they have a package, try to support as much as they can. We try to get as many supports in there as we can. Maybe the person is able to go to somewhere like the old-timers day-care program. They will pick them up on a bus and take them there. If they have a concentrator, they will carry that in as well. It is about trying to link in as many supports as possible. Sometimes it is not us doing it, but we try to make sure that the right people are there.

CHAIR: I am not sure that you were in the room when we were talking about section 100.

Mr Miegel : It is a huge issue. Poor congress have copped me banging on their door saying, 'You do everything else. Why can't you just do this for the palliative care patients?' It is hard for them and there are impacts. There are times when we provide medication out of our pharmacy budget for people. There are specialised medications like gabapentin. An indication for use is for epileptic seizures. It is an expensive drug.

CHAIR: What has come up too is off-label use. It has come up very extensively.

Mr Miegel : Yes.

CHAIR: So that is one of those off-label use ones?

Mr Miegel : That is one of those off-label use medications—an expensive medication. It can only be authorised by a palliative care specialist as well. My doctor is the one who has to do the scrips for those sorts of things as well. If that could be changed, that would be wonderful.

CHAIR: I am pretty certain comments are going to feature in the report given the number of times it has come up.

Mr Miegel : Yes.

Senator MOORE: I have one last question. Mr Miegel, where do your staff come from? I ask because of this constant issue about staffing in this. Where have you drawn your team from—not you personally, but where have the team been drawn from?

Mr Miegel : The nurse I have at the moment worked with me about eight years ago, and she has been down and worked in Melbourne. I have been very lucky to have her come back. She originally worked up here as a remote area nurse. If you know anything about remote area nurses, you know they are rugged individuals to survive out there. You last either three months or three years.

CHAIR: Or you love it.

Senator MOORE: Or 30 years.

Mr Miegel : Yes, that is exactly right. Unfortunately there are not many of those around anymore.

Senator MOORE: No, not anymore. There used to be, though.

Mr Miegel : Yes. They have great problem-solving skills, because they have to. The social worker I have used to work in Alice Springs Hospital and has done a lot of paeds work—that holistic care. She has been with me for about four years now. She is a wonderful person and keeps me on track. She is a perfectionist, so she makes me work hard. The doctor we have, Dr Nadimi, has just come up from Adelaide. She was up here as a registrar about four years ago, finishing her palliative care consultancy. She has been back and done a locum, and she is happy to relocate to Alice Springs, which is a real boon, because you can imagine recruiting doctors here.

Senator MOORE: Absolutely.

Mr Miegel : We were without a permanent doctor for about eight months last year, but we were really lucky to have Dr Michael Barbato, who has written a couple of books about palliative care and has an Order of Australia for his work in palliative care, giving us two weeks a month. So we were covered, and we also had support from Darwin.

Senator MOORE: Where was Dr Barbato come from? Is he resident in the Territory?

Mr Miegel : No, he is from New South Wales—I think northern New South Wales.

Senator MOORE: So he is one of those doctors who choose to come out and do locum.

Mr Miegel : He is retired, and we were very lucky.

Senator MOORE: That is an amazing resource.

Mr Miegel : I think that is it, unfortunately. He was here a couple of weeks ago, and I would have dragged him in with me. Even getting locum cover is a bit difficult at times for the service, and often some of the work does fall back to the nurses about liaising with the Darwin doctors and making decisions with that. But that is the reality of living in a rural area, unfortunately. My admin officer is a long-term Alice Springs resident who has two young children.

Senator MOORE: So except for the doctor—and you have been very fortunate to get someone who has chosen to come back here—the rest of your team sound as if they have been here a while, with links to the region.

Mr Miegel : Yes.

Senator MOORE: That is a very important element up here, and not common.

Mr Miegel : It is. One of the things is that I have probably recruited three staff who have done PEPA placements as well, so that has been really good.

Senator MOORE: Wonderful.

Mr Miegel : They are people who have come in with an understanding. I guess I am a little bit selective of the people I will bring into this service, just because of the work that we do.

Senator MOORE: Are you used as a training area, with people who are choosing to work and want to work in this field and also the added issue of remote work in this field? Do you get people requesting to come and do placements with you or to have training placements with you?

Mr Miegel : We have regular PEPA placements with us who come through our service. I will not lie: that does add a burden.

Senator MOORE: It does.

Mr Miegel : I have a student nurse coming next week and another one two weeks after that.

Senator MOORE: Where are they coming from?

Mr Miegel : They are coming from Charles Darwin University. They are third-year students from there. I will not take students under third year, for obvious reasons. We have had doctors from Queensland request to come and spend a week with us, just to see the differences. We had a doctor from South Australia who is on a scholarship from Thailand a little bit earlier this year as well. There are impacts, but it is also in our interest to support in that way. But there is a cost to doing that.

Senator MOORE: Thank you.

CHAIR: Thank you very much. Your evidence and time were very much appreciated.

Mr Miegel : Thank you very much.

CHAIR: It has been very important to get this additional evidence around community palliative care here. We will adjourn this particular hearing until whatever date we have in the third week in August, hopefully our final hearing—I will put my foot down—in this particular inquiry. So we will adjourn until then.

Committee adjourned at 10:50