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Standing Committee on Indigenous Affairs - 01/07/2014 - Harmful use of alcohol in Aboriginal and Torres Strait Islander communities

DIVER, Ms Hayley, Coordinator, Kimberley Community Drug Service Team, Kimberley Mental Health and Drug Service, WA Country Health Service

GOODIE, Mr Bob, Regional Manager, Kimberley Mental Health and Drug Service, WA Country Health Service


CHAIR: Ms Diver and Mr Goodie, you were here for the earlier introductions, so I will not repeat those. I remind you again that this is a hearing of a standing committee of the House of Representatives. We very much appreciate your giving us this evidence. It is being broadcast live on our internet service. These are formal proceedings of parliament. You will also recall that I acknowledged country at the beginning. Would either or both of you like to make an opening statement before we go to questions?

Mr Goodie : Our service is a regional provider of mental health and drug services. We operate a hub-and-spoke model right round the region. Our main site is in Broome. We have an acute mental health unit that was opened in 2012. We operate community mental health services—adult community mental health services and child and adolescent mental health services—and we have the drug service team. We are an integrated service, so that makes us quite unique, in a co-joined drug and alcohol and mental health service. It makes a lot of common sense up here to have both services joined as regional providers.

We have sites in Derby, Fitzroy Crossing, Halls Creek and Kununurra, and from those bases we operate a complex inreach service to remote Aboriginal communities. From the Broome site, we access the Dampier Peninsula and Bidgidanga, our largest Aboriginal community. We go as far up as Kalumburu and out to the Kutjungka, at Balgo.

We are a lean service. We work diligently to highlight the need for robust mental health and drug and alcohol services across the region. We acknowledge the investment in acute mental health service delivery. We have seen some very good outcomes from people being able to access mental health and drug and alcohol services close to home. An example is that prior to the opening of the mental health unit we would have been transferring somewhere in the vicinity of 60-plus complex mental health clients down to Perth via RFDS, complicated by anaesthetics and intubation. Since we opened the mental health unit, we have transferred only two people. We are also heavily invested in training a skilled Aboriginal mental health workforce to work within the unit with the drug service team and the community mental health team.

CHAIR: Thank you very much, Mr Goodie. Do you want to just give us a bit of an outline on how many people are employed in your mental health and drug service. Who is funding you? Are you state, federal or a combination?

Mr Goodie : We are a combination. We receive funding from the Mental Health Commission. We also receive funding from the federal government for our drug and alcohol programs. We also receive federal government funding for extra psychiatry services. That is Outreach in the Outback through Rural Health West. We also have ATSI funding for one of our positions.

When I started here, we had 42 FTEs right across the region. That was in 2007. There are 113 FTEs today. Our inpatient unit added 32 FTEs. I would like to acknowledge that it is the most remote acute mental health facility in Australia. It pays particular attention to ensuring that we have the right mix of resources to run the service. In our drug and alcohol service we have 26 FTEs across the region. I note that we had roughly 12 FTEs and then we were a successful tender to provide prevention services across the region. We have been focusing on bolstering our drug and alcohol and mental health sites across the region.

The difficulty for us, if you look at the formation of drug and alcohol services and mental health services, is that we never had a permanent presence in Fitzroy Crossing or Halls Creek. We struggled with the needs of the community in both those locations. We have been working hard to create hubs where mental health and drug and alcohol workers can be combined. That is inclusive of NGO providers, who form the surrounding layer of service provision.

The Fitzroy Crossing hub is probably about three years in front of what we are doing in Halls Creek at the moment. We will open the Halls Creek drug and alcohol hub next month. We would not be able to do that without the DAO and mental health working together. Without those sites being more robust you cannot have the sort of service configuration that is required for a community with significant drug and alcohol and mental health problems. Previously we were an in-reach service only. That would happen every two weeks, four weeks or six weeks, depending on the activity that was experienced at the site and also the resources we had to deploy there.

CHAIR: Would you take a mobile service out and then invite people at those six-weekly intervals to present as clients for support?

Mr Goodie : Yes, that is right.

CHAIR: What proportion of your clients are Indigenous and how many client contacts do you have, say, annually? I just want to get a sense of the size of your reach.

Mr Goodie : I will take the number on notice. I can provide you with a copy of our activity level. We would have at least 75 per cent Indigenous presentation in treatment, certainly in our Broome site. You would climb higher—near to 90 to 100 per cent—in our remote communities, if I can say it like that. The majority of what we see is Aboriginal mental health.

CHAIR: Who refers your clients to you? Do they come themselves? Do the local GP or nurse or a family member bring them to you? How do they come to find your service?

Mr Goodie : All of those things happen—self-referral, referral through primary care. There are not that many GPs in the region, so we operate through primary care sites and of course other service providers and family members—all of those pathways.

CHAIR: Do you have residential detox anywhere?

Mr Goodie : We do not have residential detox in the Kimberley per se. We have the ability to do detox within our hospital facilities, and then people can access residential rehab in the Kimberley. Alternatively, if that is not agreeable with people, we can assist people to access Perth residential detox and then residential rehab.

CHAIR: There are no waiting lists; people can access that quite readily?

Mr Goodie : It is always tricky. When someone identifies as being ready to access residential rehab, we do have waiting lists of varying degrees.

CHAIR: Months perhaps?

Mr Goodie : I might call on Haley to comment on that.

Ms Diver : It depends on the rehab. People often have a preference. They may want to stay close to their own family and community. Often people choose to travel outside of that. We can often find a rehab bed in a relatively timely manner if they are happy to go anywhere. If they have preference about a specific rehab then they can wait months on occasion. We have the ability though to be able to engage with that person and to work with them, often quite intensely, leading up to the point where they go into rehab so that we can offer them and their families and whoever else some support through some of our drug and alcohol workers and provide counselling support leading up to that point. We partner with Milliya Rumurra; they have a day program. Sometimes people can also choose to attend their day program before going into rehab.

Could I touch on a couple of points that Bob made, certainly for the drug service, which is a little bit different from mental health. We have a proportion of clients that are referred to us from the justice service, through either presentence or postsentence, so people coming through the justice system. We also have the Indigenous Diversion Program, IDP. As long as their offences are not too significant in terms of violence and obviously some of the sexual offences, they can be referred to the IDP. We can then engage with someone around their drug and alcohol use prior to sentencing. We provide a report then to the magistrate and they can take that into account when sentencing somebody. That is a great program that we run. We have IDP workers for magistrates in both East and West Kimberley.

CHAIR: If they are found guilty of an offence and if you have established that they perhaps have FASD or FAS they may not in fact receive a custodial sentence?

Ms Diver : The FASD issue is a bit separate to that. All of our drug and alcohol services are voluntary ones, so if someone chooses to engage in that program that is something their lawyer or the magistrate themselves can sometimes ask that they be assessed for, if that is a viable option for them. They can then choose to engage with a drug and alcohol worker. Obviously, if someone chooses not to, then we let the magistrate know that, and the normal court process continues.

Mr VAN MANEN: One of the things we have had in testimony at other hearings is the importance of finding, training and retaining Indigenous staff. Could you give us an idea of the issues you face in that regard, and how you manage to deal with that problem in order to provide your services?

Mr Goodie : I think the issue for us is having the resources to be allowed to fine-train staff. I think we are quite good at retaining staff. For example, the state government has just re-funded the Specialist Aboriginal Mental Health Service, SAMHS. That program allowed us to employ eight FTE staff and provide the opportunity and training for specialist Aboriginal mental health staff. We operate that program in partnership with the Kimberley Aboriginal Medical Services Council, KAMSC, and they have four positions.

If I were allowed to have more funding to train Aboriginal staff within my service, I think that would be highly valuable. I now have staff through that program ranging from level 7, which is the equivalent of the case managers that we have within our professional staff base, graded all the way through 6, 5, 4 and 3. I take your point that it can be difficult, but I think there are people who really want to work and be involved in health. I do not think we provide enough opportunity for that to occur. We are somewhat reluctant to recognise the cultural qualifications that people bring to the table in some sort of equivalent sense to work and integrate within the mental health and drug service.

I think the SAMHS program has allowed us to actually make our service more culturally appropriate. We know we are seeing more Aboriginal referrals, because we have the right people in place actually meeting and providing the support people require. For our in-patient unit we have a dedicated Aboriginal treatment team. That is something we specifically requested. We have a team of three Aboriginal mental health workers working alongside our allied health team. Our domestic staff working in that unit are also local Aboriginal people.

The limiting factor for me is that I have a limited budget to provide more training places for people. There could be some benefit in a traineeship program, which, by default, we start to run anyway to expose people to what a mainstream mental health service provides, and then we start to look at the cultural context in which we need to work in the remote communities.

Mr VAN MANEN: Is the training you are doing entirely in-house, or are they coming to you with a prize set of qualifications from university or TAFE or somewhere prior to their joining you, and then you are working with them to train them in relation to the cultural context in which they are working? Or are you doing all of the training in-house for the service you provide?

Mr Goodie : Like Mick was saying before, their liaison workers were working with the police and they were giving them some police education and training. People come to us with a variety of skills. I do not get people coming who already have a degree or qualification relevant to this; if they did, I would employ them straight into an equivalent position. Largely, what I see are people who are entering into the workforce as what we call an Aboriginal mental health worker.

Mr VAN MANEN: What qualifications would somebody in that position require?

Mr Goodie : I do not think there are any specific qualifications. The view we have is that they would start that process with us and then we would start experience-based learning within our service. We do have specific mandatory training that staff do with us within our service. Then we would assess the training needs and capabilities of that person. Some are doing the Aboriginal mental health degree course through Charles Sturt University. I have other staff who choose a different pathway. They may choose a pathway through allied health, social work, occupational therapy or nursing.

There is certainly another pathway around TAFE and community development. The Community Development Level III and Level IV courses also have a mental health component to them as well. They would be the baseline levels that people obtain whilst they are with us doing an Aboriginal mental health worker level IV position.

Mr VAN MANEN: It is basically an entry-level position?

Mr Goodie : Yes.

Ms Diver : Just to clarify: all positions are open to everybody. We have employed many Aboriginal people with tertiary qualifications, who have pre-existing tertiary qualifications but the qualifications do not necessary go into the Aboriginal-specific position that is part of our whole workforce. From a drug and alcohol perspective, the drug and alcohol office run the Indigenous Certificate III in Community Services Work. They have now, just this year, started the certificate IV as well. If we employ Indigenous drug-service workers who do not have a pre-existing qualification, they are invited to go to the certificate III; we certainly support the people who do. Again, sometimes we have people who would choose to perhaps do a different set of training. Whichever one they think is going to be the best fit for them, we will support them to do it. Also, we invite the mental health team to participate in the drug and alcohol training, and vice versa, as much as possible.

Mr VAN MANEN: Within that training, part of what has been discussed at various hearings is the issue of foetal alcohol spectrum disorder—et cetera. Are there components within your training to help people identify and recognise people or children who have that?

Mr Goodie : The diagnosis of foetal alcohol spectrum disorder is through fairly comprehensive testing. I do not think we make that diagnosis, even with the skilled clinicians that we have. That really requires some further formal testing. The space we want to be in is that our workforce has the ability to recognise and refer people who are presenting with behavioural disturbances and mental disturbances. They would actually be making some assessment of the social situations of people so that the appropriate referrals can be generated to service providers. I might add that the incidence of foetal alcohol syndrome is widespread. Following the Fitzroy Crossing study, we acknowledge that there is a much larger group requiring specialist intervention. This is the area we need to focus on: where do service providers fit within supporting and ensuring that the people with known presentations are getting the correct treatment?

Following that Fitzroy Crossing study, we had an influx of referrals across to mental health. The issues are around the supports that people are eligible for. I am talking about entry into supports within schools, education, training and health. There is a dilemma around the focus of what mental health services provide as an acute mental health service provider. We have some long-term development disorders. The funding for that is limited in its totality around what service providers can provide at the moment.

CHAIR: You have a diagnostic tool going through its final stages as we speak in the Telethon Institute. You would expect your formally trained clinicians to administer that diagnostic tool so that you would be able to step forward and diagnose.

Mr Goodie : Theoretically, yes. It depends on whether it is a general diagnostic tool that can be applied across the disciplines. I have a lot more mental health nurses working for me than psychologists. The testing has been specialist psychology work up to this stage. We can tell you that we know there are more people presenting with suspected FASD and there are more adults within correctional facilities with it undiagnosed. We are aware of that.

Ms PRICE: Thanks, Bob and Hayley, for coming along today. Firstly, I have a comment. We have heard a lot about the success of the alcohol management plan in Fitzroy, but I note you talked about the drug and alcohol hub that you created in Fitzroy. As a committee we are starting to get the picture that it is not just one aspect that is helping to make this a success in Fitzroy, and you have this hub as well. I am not sure how that actually operates, but the fact that there has been a lot of attention on Fitzroy speaks loudly about why this has been so successful. I also note your numbers have increased. I think you said 42 to 113 FTEs. Was that across the board—the mental health units and the drug and alcohol units?

Mr Goodie : Yes.

Ms PRICE: It is great that you have got more resources, but does that mean the problem is increasing?

Mr Goodie : No, I think the problem has always been there. The investment was in other services, and part of that would have been acute hospitals being the receiving point for people with mental health and drug and alcohol problems and then providing transport to a specialist service provider in Perth. We have been allowed to do some of that early intervention work, certainly around Broome, having specific mental health beds in Broome and allowing people to access hospital specialist treatment rather than the community tolerating and managing more acute patients in the community, because transferring to Perth was such an extreme measure and the experience for that person had some very poor outcomes. I will talk about mental health for the moment. Mental health incidence remains higher than in a metro region, per capita, I believe, and likewise the incidence of suicide and self-harm is significantly higher. It has been that way for quite a while.

Ms Diver : Can I touch on your Fitzroy comment. We have always provided a service into Fitzroy and certainly have been part of developing the alcohol management plan in Fitzroy from the beginning as well. Now we have been able to change our service model from an in-reach model to having people permanently based there, which is really good. It means that we now get out into the community surrounding Fitzroy. When we operate the in-reach model, we do not get to do that as much because we spend the time getting there and seeing that group of clients. That is useful too.

Ms PRICE: When you talked about the mental health facility in room, is that a part of the hospital?

Ms Diver : It is.

Mr Goodie : It is this a 13-bed inpatient unit with specialist mental health staff.

Mr SNOWDON: Do you have any idea of the proportion of your clients who you are seeing as a result of or in association with alcohol? What proportion of your clients do you see as a direct or indirect result of alcohol?

Ms Diver : From the drug and alcohol service about 70 per cent. I will confirm that for you but off the top of my head about 70 per cent of our clients' primary reason for referral is alcohol.

Mr SNOWDON: What about mental health?

Mr Goodie : With mental health we have a very high proportion of people with company-morbid drug and alcohol issues. Somewhere over 50 per cent would present with a co-morbid drunk and alcohol mental health problem.

Mr SNOWDON: What about in times of self-harm issues? What proportion of them are related to alcohol?

Mr Goodie : You heard the report from Inspector Sutherland. Concerning the proportion of self-harm, currently in the Kimberley we get about 15 notifications of self-harm from the police per month. They are people where police intervened and the person has been taken to a health facility. Then they advise that this person is presenting in distress and needs assessment. Of them, we know from the police data that somewhere between 60 and 80 per cent of those people will be affected by drug and alcohol or one or the other. Very few of those people are engaged in mental health or drug and alcohol services. So they are not bringing in patients we have already engaged in treatment. What we do working with the police is we respond to each and every case that is brought to our attention, ensuring that that person received an assessment and is offered an appropriate service or pathway. Many people choose not to take up that option and we have no legal enforcement to make people take that option. We do note that within our communities when people are intoxicated there is a very high level of distress and people behave in a very impulsive way. When people sober up and we reassess in the morning, people are not presenting in that fashion any longer and they choose to live without any referral. There are of course those who do require mental health follow-up after that. We appropriately follow that those people.

Mr SNOWDON: Can you give us an idea of the age range and distribution among the sexes of your clients, the people you come in contact with—what proportion are over 25, what proportion are school age, what proportion are male and what proportion of female?

Mr Goodie : Of course we have a child and adolescent mental health service. Our brief is from infants to theoretically 25 years of age. Remembering that aged care in the Kimberley commences at 45, someone who is 45 could be eligible for aged care services. We have very few people in that older age bracket who are engaged within mental health. We have a much younger population in the Kimberley. I think that a majority of our presentations are in the 25- to 50-year-old age bracket. We have a higher proportion of Aboriginal males, corresponding with females in a similar age bracket. I can provide some numbers for you, but I do not have those here.

CHAIR: That would be important, because it shows the detail.

Mr Goodie : Yes. I can give you something like that.

Mr SNOWDON: We had evidence yesterday from a magistrate, which you may have heard me talking about earlier, that there was a real issue of misdiagnosis of FASD. Given that we have only really become aware of the prevalence of FASD as a result of the Liliwan study, do you think there is a significant number of people who may have been misdiagnosed in the past who are currently out there somewhere, perhaps needing another diagnosis?

Mr Goodie : Yes, I believe that would be correct.

CHAIR: Mr Goodie, could I ask what are your personal qualifications? Are you a psychiatrist or an administrator? How do you come to it?

Mr Goodie : I am a registered nurse, a registered mental health nurse, and am a postgrad in health administration.

CHAIR: Can you tell us how many people re-present to you with a similar or exacerbated condition once you have released them from, say, the acute beds at Broome—the inpatient, for example?

Mr Goodie : One of our key reports is 28-day readmission rate. Are you suggesting that there is a revolving-door syndrome?


Mr Goodie : No, I do not believe so. We also have a mandatory seven-day follow-up report. The majority of people discharged from the mental health unit to varying parts of the Kimberley and the Pilbara—we also admit people from the Pilbara—would be referred back to the mental health team in location or their primary care provider. Imagine someone from, say, Balgo. They would be returned to Balgo or their information would go to Balgo clinic. We have a case manager who oversees people identified with mental health issues in Balgo and we have a six-weekly visit to Balgo. I think you need to know that in a lot of remote communities we would be termed a secondary provider. There is the primary care provider on the ground and we are a secondary, specialist provider adding that specialist assessment and advice, because we do not have a permanent presence around the region. Where we do have a permanent presence, in the major towns—Derby, Fitzroy and soon to be Halls Creek—we would actively follow up and engage those people.

CHAIR: What would be the average stay in one of your acute units?

Mr Goodie : Our only acute unit—I think it is going to be seven to 10 days, something like that.

CHAIR: Almost like a drying out period.

Mr Goodie : Interestingly, we do note comorbid presentations, but it is the period to establish treatment for acute mental health issues. If there is a comorbid drug and alcohol issue the drug and alcohol team—they sit within us—will make the assessment and treatment and referral for that person.

Mr SNOWDON: Do you have any step-down facilities?

Mr Goodie : They are on the way. The Mental Health Commission told us that there six step-down beds will be built in Broome in the next couple of years. This is really necessary, especially for people who need to be returned to more-remote locations and need a longer length of stay in supported care.

CHAIR: Thank you for your attendance today. Mr Goodie, you are going to provide us with some data. We appreciate that very much. You will receive a draft transcript of the evidence you have given today which you can check and correct any misunderstandings or mishearings. I understand that you have been very flexible with your time, and we appreciate that you have been able to roll with the evolving program.

Proceedings suspended from 14:45 to 14:57