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Standing Committee on Indigenous Affairs - 04/05/2015 - Harmful use of alcohol in Aboriginal and Torres Strait Islander communities

BYRNE, Ms Shaun, Drug and Alcohol Worker, Community Health

CRISMANI, Mr Christopher, Acting Executive Officer and Director of Nursing, Coober Pedy Hospital, Country Health SA


CHAIR: Welcome. I note, Mr Crismani and Ms Byrne, that you have been here most of the day, so I will not need to re-brief you on the names of the members of the committee or the protocols of this hearing. You have just handed us some information, for which we are grateful. Did either of you wish to add anything about your work or the capacity in which you are appearing here today?

Ms Byrne : I work for three days a week at Community Health. I am an accredited mental health social worker.

CHAIR: Would you like to make an opening statement?

Mr Crismani : I would like to thank the standing committee for taking the time to travel to Coober Pedy and speak with the local people about the issue of harmful alcohol use. The Coober Pedy Hospital and Health Service is funded as a multipurpose service, MPS, model. It works to create closer links between services in the diverse communities of the area, and its ability to adapt to the changing circumstances of the region. It is a minimally staffed hospital. This means that there is only one registered nurse and one enrolled nurse per shift, plus a carer 0.4 full-time equivalent to care for the residents. There are three shifts over a 24-hour period. The Coober Pedy hospital is the only one on the Sturt Highway between Port Augusta, 550 kilometres south, and Alice Springs, 670 kilometres north. As well as providing services to Coober Pedy and the surrounding towns and stations, the hospital provides a service to road trauma. The hospital has 20 beds: 15 are for acute, one is for palliative care and there are four high-level residential aged care beds. The hospital has a 24-hour accident and emergency department, and an X-ray facility, which is provided by credentialed registered nurses and is available by appointment, if needed, or for after-hours emergencies. This X-ray facility requires a referral from a medical practitioner.

Health care in Oodnadatta is provided by the Oodnadatta clinic, which is also managed by the Coober Pedy hospital. Ties with the Marla nursing clinic have been developed by Coober Pedy hospital and the health service has developed a responsive communication with Umoona Tjutagku Health Service Aboriginal Corporation and the Umoona Aged Care Aboriginal Corporation. We have relationships with a lot of community service departments that have continued to develop in the interests of community support.

The Coober Pedy Hospital and Health Service employs an Aboriginal liaison officer and an Aboriginal patient pathway officer, Ian Crombie, in his role with the hospital.

Ms Byrne : He has a lot of hats!

Mr Crismani : Their roles are to assist Aboriginal people to navigate the health system, understand the health system, and break down the language and cultural barriers in our service. The ultimate aim is to improve health outcomes of Aboriginal people who access the hospital and health service.

Additionally, there is a purpose-built Aboriginal aged care unit that is adjacent to the hospital and is managed by the Umoona Aged Care Aboriginal Corporation. Clinical services are provided to these beds on request either by the Coober Pedy Hospital and Health Service or the Coober Pedy Medical Practice. The hospital is collocated with an active community health centre, the Royal Flying Doctor Service and MedSTAR provide evacuation support, and the local ambulance service provides transport for medical emergencies in the community.

Coober Pedy's isolation and remoteness provide a challenge for recruitment and retention of staff. Failure to attract and appoint staff at all levels has impacted and causes a strain on the organisation. Often agency staff have provided backfill for nursing positions. Positions can be vacant for lengthy periods. The hospital is staffed by medical officers on a locum basis. They fly in for a two or three week period and then fly out. We have worked to reduce the different number of locum medical officers so that there is a bit more of a consistent medical approach in the community.

Today I intend to focus on the trends in and prevalence of alcohol related harm, including alcohol-fuelled violence before and after the changes to the liquor licensing laws in Coober Pedy. The data I present comes from the paperwork completed by nursing staff in the hospital for every presentation or admission and is then entered into the database used by Country Health SA. This database is called CHIRON. Coober Pedy has an ageing population, and with that there can be a number of chronic health issues. There are over 40 different nationalities in the community, with English as a second language for a number of people presenting to the hospital. The Aboriginal population I am quoting is 30 per cent, but you had an earlier figure that differed, I think.

Mr COULTON: 24 per cent.

CHAIR: About 24 per cent. But you think it is 24 to 30 per cent?

Mr SNOWDON: Closer to 30, isn't it?

Mr Crismani : It would be closer to 30. A number of people in the community are reluctant to present to hospital, and so when they do present they can be more unwell and will require longer admission and/or transfer out by RFDS or MedSTAR. Coober Pedy hospital does not do delivery of babies. It is recommended that mothers leave the community at 36 weeks to ensure appropriate care can be provided. The community midwife would identify high-risk deliveries and liaise with the family and relevant receiving hospital.

As was mentioned earlier in the day, there has reportedly been a reduction in the number of callouts for SAAS and SAPOL. Hopefully that data will be provided by those agencies. As in any city based hospital service, not every callout of SAAS or SAPOL results in a presentation to the local hospital. So if the callouts to the ambulance service, for example, have fallen by 50 per cent, that does not necessarily mean that presentations to the hospital will fall by the same amount.

Most of the presentations to the Coober Pedy hospital are in fact self-presentations. People either walk in or drive themselves to the hospital. In the period since the introduction of the changes to the liquor licensing laws in Coober Pedy, from October 2012 to September 2013, as compared with October 2013 to September 2014, the overall number of emergency type presentations to the Coober Pedy hospital decreased by about 14 per cent. That is in the first year post the changes to the liquor licensing laws. In that same period the number of Aboriginal people presenting to the hospital accident and emergency department was 1,081. In the following period it was 895. This represents a decrease of about 17 per cent in hospital accident emergency department presentations by Aboriginal people for this period. Over the same period the number of non-Aboriginal people presenting to the hospital decreased by about 11 per cent.

Moving to the charts. The chart on page four denotes the changes in emergency type presentations by Aboriginal people over the period October 2012 to September 2013 and then from October 2013 to September 2014, with the period prior to the liquor licensing laws changing appearing in blue, and the period after the liquor licensing changes appearing in green. Of note is that there is a decrease in psycho-social presentations of about 17 per cent; a decrease in lacerations of about 34 per cent; a decrease in respiratory problems of about 16 per cent; a decrease in abdominal problems of about 13 per cent; a decrease in musculo-skeletal problems of 33 per cent; and a decrease in cardiovascular problems of 31 per cent. Of note is that ENT or oral presentation increased by 10 per cent.

Mr SNOWDON: Lacerations and musculo-skeletal means that people are not being bashed. What is the explanation for the cardiovascular decrease?

Mr Crismani : Probably chronic health issues.

Mr SNOWDON: In this set of data the obvious ones are 34, 33 and 17. The less obvious one is cardiovascular. Presumably we are saying that the same people who are getting bashed had cardiovascular problems or chronic diseases anyway.

Mr Crismani : It could be that the alcohol consumption had an impact on the cardiovascular disease.

CHAIR: There is a known link between heart disease and alcohol consumption.

Mr SNOWDON: There is a very high correlation between the three figures.

CHAIR: So you are seeing a much healthier population through your accident and emergency department since 2013?

Mr Crismani : What we are seeing is a different population coming through the accident and emergency department and to the in-patient unit. The figures, as the charts go on, will demonstrate that there is an increase in admissions from November, December last year. It was a very busy period and that has actually rolled over and continued into the first three months of this year.

CHAIR: What was the cause of that increased activity?

Mr Crismani : Unknown.

CHAIR: But it was gender based violence still?

Mr Crismani : The presentation type is different, and that is what these statistics are reflecting.

CHAIR: And this is heart disease and those other sorts of conditions?

Mr Crismani : Yes.

Ms Byrne : There has been an increase in oral presentations. It is quite common when people are in in-patient withdrawal units that they are actually start to feel the pain. Alcohol is a good pain relief—it is one of the best pain relievers—

Mr Snowdon interjecting

Ms Byrne : It depends on what you drink, I suppose! So that is one of the things that people are doing when they are going through rehab. They have noticed that their teeth are sore and they are getting some assistance with that.

CHAIR: And their other conditions become apparent. We had that same evidence from Fitzroy Crossing. When people were weaned off a lot of very high alcohol use, they then started to present with a whole range of other medical conditions, particularly mental health conditions, which led to their FAS-FASD work.

Mr Crismani : We did have a number of people presenting with toothache and requesting Panadeine Forte to treat that. Upon reflection, we wondered whether that was in fact a substitute.

Mr SNOWDON: I notice a 30 per cent increase in people seeking treatment for alcohol misuse. That might explain—

Mr Crismani : Yes. I could go on to talk about the drug and alcohol presentations.

Mr SNOWDON: I was just looking at this chart, which talks about reduction on page 6. It refers to reductions in the obvious but an increase in people seeking treatment.

Ms Byrne : Yes. That is correct.

CHAIR: So, having less access to alcohol, they are then seeking more treatment?

Mr Crismani : We identified a number of people that were frequent presenters to the hospital, and it could be that that small number of people caused an increase in the number of presentations. It could be that the restriction on supply or it being not as easy to access supply has then caused people to seek treatment for alcohol related issues.

Mr SNOWDON: You would have to think, given the overall data, leaving aside the 30 per cent, that there is a greater feeling of wellbeing in the community because there is less abdominal pain, less chest pain.

CHAIR: This is excellent data, and let me thank you for it, but we are running out of time. We have still got one more group to hear and we need to finish at 2.30. Has anyone got very precise questions to ask? Perhaps when we interrogate the data you have given us, we will be coming back to you. Graham has got a particular question.

Mr PERRETT: It is the obvious one. I know you are not a GP in the community, but, with the locum turnover, as the locums do not have the local knowledge or connections with the community, surely the health of Coober Pedy suffers because of that.

Mr Crismani : It would be good to have a consistent medical officer in the hospital.

Mr PERRETT: There is a GP in the community?

Mr Crismani : There is a community GP who does not have admission rights to the hospital, but, as I said earlier, we do have a number of locum GPs. We have reduced the number so that the GPs coming back are more familiar with the community and the hospital.

Mr PERRETT: You have only got carrots to offer, I guess, in terms of bringing people in—and not many carrots.

CHAIR: Do Indigenous patients use the private GP? Does he or she bulk-bill, for example? They do. Do Indigenous patients go to that community based GP?

Mr Crismani : They do.

Ms Byrne : It is Dr Kami.

CHAIR: So he would have another sort of data about presentations to him.

Mr Crismani : That we would not have access to.

CHAIR: You talked about how women who need to deliver go somewhere else six weeks before the birth. You then implied the midwives were assessing those cases that were regarded as high risk. I understood every birth is required to—no-one is allowed to give birth on country. Is that the case?

Mr Crismani : I am not sure about where they are allowed to give birth, but we are not a—

CHAIR: They are not allowed to finish their pregnancies and be delivered here in the community—that is the case.

Mr Crismani : That is right.

CHAIR: Even if it is a low risk.

Mr Crismani : Yes, but they may want people to travel out of town earlier. They would certainly—

CHAIR: And six weeks before the birth, if it is a high risk.

Mr Crismani : notify the hospital of those people being in the community so we are aware.

Ms Byrne : We did try to condense this report, obviously, but one of the other parts of that sentence was that, if a woman has been identified as being a drinker or else using a lot of cannabis, we would certainly inform the hospital that she is attending. The community midwife and I have put in notifications to Families SA for what we consider high use of either alcohol or cannabis during pregnancy. So we identify those high-risk deliveries and then negotiate with the hospitals in Adelaide.

CHAIR: It is not only high-risk delivery but the likelihood of the child being born brain damaged.

Ms Byrne : Yes, and we have had babies that have gone through withdrawals because of both cannabis and alcohol post delivery.

CHAIR: But also FAS and FASD presentation.

Ms Byrne : Yes.

CHAIR: Thank you for this excellent data. Mr Crismani, you wanted to make another point.

Mr Crismani : Earlier it was mentioned about the number of females in the sobering-up unit outnumbering the number of men. On page 16, you will see that the number of women who present to the hospital is about 57 per cent.

CHAIR: That is interesting. Is there a reason for why that is the case?

Mr Crismani : It could be that it is a safer place. It could be a result of violent incidents—these are suppositions. Going towards the back of the presentation on page 19—George alluded to this also—is the reduction in the number of deaths. There is a red line that marks the introduction of the changes to the liquor licensing laws. The first number prior to that is about 35, and after that the number was about 19 the following year. This year there have only been two deaths in the community in the first four—

CHAIR: Related to alcohol.

Mr Crismani : These are total deaths in the community.

Mr RAMSEY: When you get an alcohol related death, you are talking about virtually to the point of poisoning; you are not talking about long-term cirrhosis or something like that.

Mr Crismani : It could be cirrhosis of the liver. It could be heart failure. It could be renal failure, so we are not able to say: 'This is an alcohol related death.'

Mr RAMSEY: That is unlikely to dry up for quite some time, is it? There are a lot of long-term issues.

Mr Crismani : But there has certainly been a reduction in the number of deaths in the community. On the following page, on page 20, it reflects the number of recorded incidents of challenging behaviour towards staff in the hospital, and so there is a significant drop-off in those incidents that have been recorded and reported following the changes to the liquor licensing laws, which changes the environment that care is delivered in the hospital.

CHAIR: That is very interesting, thank you, and the dip in the 2011 number of deaths as well is very interesting, bearing in mind they are very small numbers, but it is interesting to observe. We thank you most sincerely. We acknowledge you have been here a very long time today. We thank you for taking all of that time. If there is anything in addition that you wish to add, please do so. If we have more questions related to your data, we will get back to you. A transcript will be supplied for you to check for accuracy. We have often been full of anecdotes but short on data, haven't we? It is marvellous to have some good data to use—thank you—particularly, related directly to a program that has been introduced.

Ms Byrne : Obviously, my position is for 18-plus but, in previous work that I have done here, I do think that FASD is an issue and it has been underdiagnosed and underreported. The process here is: if somebody identifies that a child might have that issue, they have to then see a paediatrician who specialises in that. So we might have a visiting paediatrician but they might not specialise in that, so then the child has to be assessed. I know of cases where they have had to go to Adelaide for that. So there is a whole process around that and then what supports are in place for the school or whatever for them.

CHAIR: So it is a serious problem.

Ms Byrne : Some forms of medication have been shown to be effective on the behaviours, but not on the attention span. That has certainly been my experience.

CHAIR: The cognitive damage is a major problem. We thank you most sincerely.