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STANDING COMMITTEE ON ABORIGINAL AND TORRES STRAIT ISLANDER AFFAIRS
04/05/2010
Involvement of Indigenous juveniles and young adults in the criminal justice system

CHAIR —I am very pleased to welcome representatives from the Mental Health, Alcohol, Tobacco and Other Drugs Service, Dr Peter Steer and Dr Aaron Groves. Our normal procedure is to ask you to make an opening statement, and then we will have a discussion if that is suitable to you.

Dr Groves —Thank you, Mr Chair. I will commence by clarifying an aspect of our representation. We are representing Queensland Health. There seem to have been a few glitches in the practical issues of making sure that the committee was informed that we would be representing Queensland Health and not just the Mental Health, Alcohol, Tobacco and Other Drugs Service of the Children’s Health Service District. My role is as the person responsible for policy, planning and mental health services reform within Queensland Health, and Professor Steer’s role is as the person responsible for all of the Children’s Health Service District services, including those that relate to mental health.

I would like to thank the committee for the opportunity to come along and give evidence to you about a very significant issue for mental health services within Queensland. I would like to start by acknowledging the traditional owners of the land which the committee is on, the Yuggera and Turrbal people. Given the presence of other people in the room, I acknowledge other elders and thank them for the safe passage of the committee. I am also here on behalf of Mick Reid, who is the Director-General of Queensland Health. Unfortunately, he cannot make it to give evidence to the committee.

I thought I would start by perhaps giving the committee a little bit of background as to why this issue is so important for mental health services. You may be aware that Australia has had a National Mental Health Strategy since 1992. In fact, one of the founding documents of that was a National Mental Health Policy. One aspect of that policy that became very clear was that, while probably good at the time, it was not contemporary, and in 2008 that policy was revised. An important aspect that I would like to draw the committee’s attention to is on page 7 of that policy, where the policy acknowledges for the first time—I suspect probably for the first time in any national health policy document in Australia—‘our Indigenous heritage and the unique contribution of Indigenous people’s culture and heritage to our society.’ I will read further. It says:

… it recognises Indigenous people’s distinctive rights to status and culture, self-determination and the land. It acknowledges that this recognition and identity is fundamental to the well-being of Indigenous Australians. It recognises that mutual resolve, respect and responsibility are required to close the gap on indigenous disadvantage and to improve mental health and well-being.

That is a direct quote from the national mental health policy. The policy has been operationalised through three five-year national mental health plans and a fourth one that was endorsed late in 2009, before the discussions that have been going on around the National Health and Hospitals Network Agreement that was endorsed by COAG only last month.

The fourth national mental health plan for the first time picks up Indigenous mental health issues and social and emotional well-being and describes how they need to be taken forward. An important aspect of that is that action 7, which is in the very first priority of the fourth plan, talks about taking the current Aboriginal and Torres Strait Islander mental health and social and emotional well-being framework, redoing it, updating it and implementing it. There has been a fair degree of concern that that Aboriginal and Torres Strait Islander framework probably did not get the degree of attention in its implementation over the last five years that it needed.

Within Queensland Health and in the Queensland government we endorsed the Queensland Plan for Mental Health, a 10-year plan, during 2007, with approximately $1 billion of funding going into mental health over the first five years. An important key element of that is the way in which we work across government. The plan is not just a Queensland health plan; it is a Queensland government plan. It looks at those responsibilities that would be taken forward by the Department of Communities, the Department of Justice and Attorney-General, the Queensland Police Service and so on—and I recognise that many of those government agencies gave evidence to the committee this morning. An important aspect of how the mental health, alcohol, tobacco and other drug services—MHATODS, as they are affectionately known—have worked is that they have been a key part of how we deliver services into detention centres, both the Brisbane Youth Detention Centre and the Cleveland centre in Townsville. We are trying to ensure that youth who end up in detention get access to the full range of services that should be made available to them.

The health status of youth in detention has been well described in this country as poor. Their mental health status has been variably reported because, unfortunately, there has been nowhere near as much research of youth in detention as there has been of adult prisoners, and that is clearly a major gap. What we do know is that, whilst approximately four per cent of the Queensland population identify as being Indigenous, probably as many as one-quarter of those people in youth detention are people who have been sentenced. We also know that the proportion of people in youth detention who might identify as being Indigenous is probably more like 50 per cent. We know that is the case in Brisbane and it is probably closer to 80 per cent in Cleveland. This overrepresentation of youth is a significant issue.

We are also aware from data that has been collected from MHATODS that these kids have often had mental health and substance abuse problems before they have come before the criminal justice system and entered youth detention. One of the significant issues is that, despite that high prevalence, we know that they do not access the services in the community before they get into prison. So it actually affords an opportunity to make sure they get access to those services. If anything, the evidence suggests that they are more likely to get services once they are in youth detention than they were when they came from their communities. That is a worrying thing from the perspective of what happens in the community, but it is a good thing in that, once they are in youth detention, we make sure we address their issues.

Part of the strength of the submission is the way in which MHATODS have gone about trying to ensure they provide a very holistic approach to what happens in youth detention. It is not just about assessment and screening of the kids; it is making sure that they actually get into services that are appropriate for them. Queensland Health’s approach has been to make sure that not only are their mental health and substance abuse needs are met but also their sexual health needs and their oral and dental health needs are met at the same time. This is a comprehensive package of which MHATODS represents just one aspect.

Another aspect of the submission is the reinforcement of the fact that the approach of MHATODS is also to look at those custodial staff within the correction centres and make sure that they are trained to recognise problems early, to know why people are screened and assessed and to know how treatment services should be applied and the correct way of helping to deal with people with problems once they are in youth detention. In addition to that, it is important to make sure that, if somebody is leaving detention, there is a comprehensive package with all those government departments that should be responsible for following them up in the community made available.

I understand the submission has also made recommendations around the development of national guidelines in a number of key areas. This is an important aspect that Queensland strongly supports. There are mechanisms that are now available in terms of implementing the fourth National Mental Health Plan that will start to address those issues. We certainly intend to put that very strongly on the agenda of what is called the National Comorbidity Initiative. It is a committee of health ministers and it is responsible for looking at addressing mental health and drug and alcohol issues jointly as opposed to separately. I think the submission has highlighted the fact that the National Drug Strategy and the National Illicit Drug Strategy have sometimes been separated out from the National Mental Health Strategy and that those two need to come together and particularly in youth and particularly in Indigenous people this is important. I will pause there. I am not sure if Professor Steer wants to make any other comments but then I am happy to field questions.

Dr Steer —I think it has been a fairly comprehensive introduction. I am happy to take questions.

CHAIR —You have laid particular emphasis obviously on young people in detention. I know from a lay point of view that nationally we have been paying less attention to the mental health needs of young people at large regardless of their backgrounds than we might have. There are various attempts to overcome that shortcoming now. Can you to talk about issues of mental health and substance abuse in Aboriginal communities as distinct from the issues in detention centres?

Dr Groves —I think it is difficult to make sweeping statements because not all Indigenous communities are the same in Queensland. There are some communities that are inherently very strong. They have the strength of their cultural background that has been quite protective and so we see a lot fewer drug and alcohol problems and subsequently mental health problems in those communities compared with others. There are some communities that have perhaps distinguished themselves from former Queensland government policy and that is particularly the ex-DOGIT communities, but there are a number of other communities throughout Queensland where a number of problems that really started to rise in the 1970s, essentially around drug and alcohol and substance use, have tended to then cause a generation of problems. We saw very high rates of alcohol and drug problems commencing in the seventies and eighties. Then subsequent to that we have seen high rates of mental health problems and in particular psychosis start to develop in the eighties and nineties.

Even more tragically we have seen what was essentially a very rare event prior to the 1960s and that is suicide in those Indigenous communities become a very, very significant problem. We see rates of suicide in those communities—again I am talking about those same communities and going through a similar path—being significantly higher than non-Indigenous communities and significantly higher than those Indigenous communities where there has been the preservation of the cultural identity and some cultural strength within those communities. That is I suppose a thumbnail sketch. At its most significant end we have communities in Queensland where rates of mental illness amongst youth are well in excess of what would be seen in the non-Indigenous community in Queensland, where rates of alcohol and in particular substance abuse are almost endemic, and where suicidal behaviour as opposed to actual suicide is again very common practice. These are of major concern to the government.

Dr Steer —Also more specifically as to some elements of our ignorance with respect to the urban Indigenous population, we have virtually no real understanding of the statistics and risk for that youth population, although we are concerned about it. It is early and it has been a neglected area for our own evaluation and research.

Dr Groves —I think the submission also refers to the lack of identification of mental health and drug and alcohol problems in the Indigenous community in Australia in general. We could update that by saying that in 2007 the ABS conducted the second National Survey of Mental Health and Wellbeing. For the first time it had an Indigenous identifier. Sadly, the completion numbers are too low for the first report that came out—called The mental health of Australians 2—to unpack the rates of mental health problems among Indigenous people. What we do know is that the National Health Survey, which is reported by the ABS and the AIHW, has shown that rates of distress in Indigenous people are significantly higher than in the non-Indigenous population. They are probably twice the rate of the non-Indigenous population and we know there is a very strong correlation between that and the presence of mental illness. So we have some presumptive evidence which says that their problems are significantly more, whether in urban or rural and remote communities.

Ms REA —In your submission you talk about Indigenous health workers acting as cultural brokers. Earlier today—and indeed in other evidence—we have heard from the community and Indigenous community organisations that one of the difficulties they face particularly in dealing with government agencies is the lack of Indigenous people who are employed. Therefore, not only do you have just the barrier of walking into a fairly mainstream office that is pretty imposing and intimidating, but you are not talking to someone who you feel that you can relate to. I wonder if you could explain a little more about what they are doing within the program and the effectiveness of what they are doing.

Dr Groves —I might start off by making some general remarks and then get into the specifics. Unfortunately, I am unable to tell you exactly how many Indigenous health workers we have within Queensland Health, but I do know that we have approximately 91 Indigenous mental health workers. These are people who work within mental health services who are employed to do a variety of different roles. I suppose one of the concerning aspects from my perspective is that we do not currently have a uniform identified role for all of those Indigenous mental health workers. It is not as if they have the same job description. I think that is a significant problem that we are attempting to address. The Queensland plan for mental health talks a little about that.

The first point to get across to the community is that we do not do too badly in mental health when it comes to Indigenous mental health workers. We have established a benchmark for Indigenous mental workers in Queensland government that we are trying to look toward reaching. That is one per 1,000 Indigenous population of Queensland. We are probably halfway there. We may need somewhere in the order of 200. We believe that would provide us with a very sound basis for how those people could work effectively within our services. How they specifically work within MAHTODS is that the staff are responsible for cultural brokering and cultural understanding not only for the other staff who work within those services but also for the Indigenous persons so they get a better understanding of what the service is about, what they are going to do for them. I think that there is a greater acceptance amongst Indigenous people when they can identify somebody from their own mob who can say, ‘Look, these people are good. They are to be trusted. They are here to help. This is what they are about.’ It is that degree of recognition and understanding that often goes a significant way to getting people to engage in services rather than being disengaged. You comment about local Indigenous community people, saying that it is pretty scary accessing Queensland Health. I can tell you it is pretty scary for non-Indigenous people. Therefore it is an order of magnitude worse for Indigenous people.

So I think anything we can do that makes it culturally safe, as opposed to just culturally appropriate, is a really important aspect of what we need to do. I think that the role of Indigenous health workers within MHATODS is not just about making it culturally appropriate; it is about making it culturally safe. I think that is an important paradigm that we are trying to get across in all of our mental health services to a greater or lesser extent. I think it works better in some areas. Probably within child and youth services in general we are doing better, but there is still room for improvement.

Ms REA —Are those workers just treating the young person in particular as a client on their own or do they liaise with their family and community? Is there a broader approach or is it very much a clinical dealing-with-a-patient type situation?

Dr Groves —No, in fact it is a very clearly defined non-clinical role. They do not just take the person on for case management; it is very much around brokering all the cultural needs of the person, and it includes their family, any other kin they might have and any other people within the community who they might be able to access. Again, there are difficulties and complexities in doing that, but that is what that role is identified to do.

Mr TURNOUR —Are these mental health Indigenous workers specific to mental health or are these the health workers that I run into in Queensland government health clinics all across the cape who do a whole range of other services as well? Is that what we are talking about or are we talking about Indigenous specific mental health people?

Dr Groves —I am talking about the Indigenous specific mental health workers of the MHATODS team. What you will see is those same Indigenous staff clearly right throughout Queensland government. The mental health specific role is a little bit different from some of the other Indigenous health worker roles.

Mr TURNOUR —You talked about suicide being a particular problem in Indigenous communities. What specific programs have you got running for Indigenous communities that address suicide issues?

Dr Groves —I think that is a complex question that I can probably talk about for way too long. So maybe I will try and—

Mr TURNOUR —I just want a simple answer.

Dr Groves —I will try and address it by saying that there really is a response at two levels of government. The first way we look at it is that Queensland government tries to take a broad approach to suicide prevention where multiple different government departments have been involved in what we currently know as the Queensland Government Suicide Prevention Strategy. It outlines a number of different tasks. It highlights that Indigenous communities are a priority area and that activity needs to occur there. That strategy is now complete. It finished in 2008. It has been evaluated. It is informing the new Queensland government suicide reduction action plan which is in the final stages of development.

You can understand that, unfortunately, because it has not yet been endorsed, I cannot talk about what is being considered for the future. However, I can say that the programs that we have fall into three broad categories. It is those services that are direct treatment types of services—that is, when somebody is identified as having a mental health problem or being at risk of suicide, it is how they get assessed, how they get access to treatment and how we make sure that they are followed up in the community until such time that they are not considered to have suicidal risk.

There programs that are about identifying what factors in communities might be leading to high risk and trying to immediately address them. They can be anything from the strength of the community through to if suicides occur how postvention occurs. It can be support for people who are bereaved right the way through to those types of programs that are specific to groups we have identified as being at risk. Say, for example, if we know that there is a cluster of suicides within a community, we will generally look at one of our community mental health services getting engaged with that community and trying to address what the underlying problems are. The best example I can give you in your part of Queensland is the rural and remote outreach team that is headed by Ernest Hunter in the cape, which would frequently go to communities if there has been a suicide and would try to address whatever underlying problems there might be.

Likewise, if that then becomes a pattern over a longer period of time when there is recognised to be a problem that is not going to be addressed just by one-off intervention or over a few weeks, they will then look at putting an intervention into place that can be there for a much longer period of time. An example of that was Yarrabah, where an ongoing service was developed that has now been going for well over a decade.

One of the complexities is that—and I will be careful about how I choose my words here—there has not been a good alignment between the suicide prevention activity that the Commonwealth government has led and that which has been led by state and territory governments. I am aware that other committees in other places have looked at that particular issue. The way in which that is now being addressed is that the fourth plan has talked about state and territory and Commonwealth activities needing to be aligned under the fourth plan. I can think of numerous examples where there was overlap, where the state—

Mr TURNOUR —Could you explain that.

Dr Groves —I can give an example and then say how we are trying to align them. A good example would be that the states have often taken the responsibility for funding non-government organisations to do work in the broad area of, for example, social and emotional wellbeing as a way to reduce the likelihood of suicide in communities, only to make announcements that services would be provided in one part of Queensland and then find out that the Commonwealth had just announced almost exactly the same thing from a different provider in exactly the same area the day before. That type of lack of coordination has caused considerable concern within the communities because they do not know how the two different programs might work, how they operate and so on.

The other aspect is that it has generally been considered that the Commonwealth has taken the lead role on funding postvention-type services but the state often picked up where they have realised there is a problem that needs to be addressed in the absence of the Commonwealth having sufficient funding to do that. And then you end up with the question: who does take the lead role in funding those types of issues? How it is being addressed, to answer your question specifically, is that action 13 of the fourth plan talks about needing to have state and territory and Commonwealth initiatives aligned.

There was an initial meeting convened by the Commonwealth in which the national suicide prevention strategic framework—which is a good document that tries to outline how we should go about addressing suicide prevention, even though that is not what the two levels of government have been doing—was put up for national endorsement for the first time. The states have now agreed that the way in which we will go about addressing suicide prevention will be consistent with that framework. There had not been an agreement before, so states would go about doing it in one way and the Commonwealth would do it in another way.

It has also led to a much more open dialogue between the Commonwealth and its programs around where they intend to fund as opposed to what happened before, which was they would just fund. If I can give a practical example of that, one of the Commonwealth Department of Health and Ageing officials contacted me some six months ago and said, ‘We plan to do this north and south of Brisbane.’ I said, ‘Well, if you plan to do that, we were planning to do something very similar. Instead, we will do this, which will complement that.’ This project was about following up people with their general practitioners when they present to emergency departments but do not need admission. What has happened is that the Commonwealth is funding the general practitioner arm of it and we are funding the mental health service arm of it to make sure that people do not slip through the cracks between those services as opposed to us potentially having both funded the same thing. That is a practical way in which Commonwealth and state programs are attempting to be aligned rather than duplicated.

CHAIR —Obviously there should be more of it.

Dr Groves —I would totally agree.

Mr TURNOUR —We have agreement that we are moving to community control in your section of the health department, as you outlined. How does the mental health area fit with the broad thrust that we have all signed up to in relation to community control in the more acute primary and preventative health areas? How do you fit with that model? How do Apunipima—in my part of the world—Queensland Health and RFDS all fit together? They are all involved in those sorts of services.

Dr Groves —I think there are two aspects to your question. The first is the question of the funding to non-government organisations from the Queensland government. In July 2007 they were transferred over to the responsibility of the Department of Communities, so the Department of Communities now are responsible for funding mental health NGOs in Queensland, not the department of health. It is a unique arrangement in Australia. We are the only state in which Health does not fund the mental health non-government sector. How that practically works is that Queensland Health retains the policy- and direction-setting role. If we believe that there are insufficient community organisations in a particular community from a mental health perspective, we would identify that and the Department of Communities would look at, within their funding envelope, how they would actually address that issue. That is practically how it is supposed to work.

How it has occurred is that, under the Queensland plan, there has been significant new investment in the mental health non-government sector during the last three years. For example, four years ago the Queensland government spent about $12 million on the community mental health sector; this year it is expected to spend about $50 million. So there has been sizeable growth in the sector. It is fair to say, however, that it has been a bit patchy and ad hoc. At the same time, the Commonwealth has rapidly expanded its investment in the non-government sector through a number of programs, some through FaHCSIA and some through DoHA. Again, it is fair to say there has been some overlap of some of those programs with what the states provide.

I think the second aspect of your question is: how does what was signed up to by COAG last week in terms of who is responsible for what aspects of mental health—am I decoding what the second half of your question was?

Mr TURNOUR —The department of health, community controlled organisation Apunipima and RFDS all deliver services into Cape York, for example. RFDS has wellbeing centres, you employee Ernest Hunter and others, and Apunipima are out there running GP and other services. Is that part of the mental health transition plan for the broader cape area, for example?

Dr Groves —The simple answer at the moment, as best as I can understand it, is no. We would see Queensland Health as being responsible for providing specialist mental health services—that is, those services that are usually not provided by primary care. Apunipima we would see as being more about providing the more primary care services. The difficulty is there is no boundary between primary mental health care and secondary care or even tertiary care that is defined anywhere, so it is a very grey area. Ernest Hunter’s role has often been to support the Apunipimas of this world, in terms of doing their role as best as is possible. But, if they have individuals whose mental health needs are greater than their expertise, then they would refer to Ernest’s team and there would be a joint working relationship about what would occur.

The relationship between Ernest Hunter’s rural and remote team and Apunipima is probably one of the best that we have in Queensland, and that is how it should look. How it will look into the future, though, is unclear because, in the National Health and Hospitals Network Agreement that was signed, the actual role of specialist mental health community services remains unclear. There is the description around community health moving to the responsibility of the Commonwealth, and that is clearly understood. It does not seem to be clear where specialist mental health services arise. I can foresee, for example, the difficulty where somebody might be on an involuntary treatment order under a state mental health act: it would be rather difficult to prescribe to the Commonwealth what to do about the care that would be needed for that person in terms of specialist care. So the primary care issues are straightforward; the specialist care issues are much more unclear and need to be worked out.

CHAIR —This is a general problem, though, not a problem that is exclusive to Aboriginal communities.

Dr Groves —It is a general problem; however, it is a much more significant problem in Indigenous communities because community controlled health organisations have a very central role and are separate from what would traditionally be provided by Queensland Health. Mr Turnour’s question is quite appropriate, in that it is blurrier for Indigenous committees than for non-Indigenous communities.

CHAIR —The reference to Indigenous NGOs causes me to recall evidence that was given to this committee in Fitzroy Crossing in the Kimberley. I am sure you are aware of the famous film that has been made about the change that occurred in that community when drinking laws were altered. The alteration itself came about because of some Indigenous organisations within Fitzroy Crossing—led, as I understand it, by health workers, but in any event health workers were prominent in the agitation. That change led to quite profound alterations to behaviour in the community, but my understanding is that the whole exercise was partly motivated by an extraordinary number of suicides over quite a short period. It was the final desperation felt because of those suicides that brought about the great change.

It all leads me to ask you to make some comment on the role of Indigenous NGOs. We have had evidence as recently as an hour ago to suggest that there is frequent frustration within the Indigenous community that Indigenous controlled NGOs get pushed aside by other kinds of NGOs and are not permitted in the end to have the kind of authority that I have described as being very effective in Fitzroy Crossing.

Dr Groves —Perhaps I should declare that I was director of mental health in Western Australia for four years before I came to Queensland in 2005. I am very aware of the significant problems in Fitzroy Crossing and all of the Kimberley. Indeed, my comments in relation to alcohol and drug problems, mental health problems and suicide problems in the Indigenous communities of the Pilbara and Kimberley are that they are much the same as what has occurred in Queensland and the Northern Territory. This is an Australian problem and an issue of Australian governments from a long time ago. That, I think, is well understood, at least in academia and in mental health policy direction. I understand that.

As a Queensland government official, all I can say is that we have processes in place through the Department of Communities that attempt to ensure that that problem that you have described is addressed—that is, that Indigenous non-government organisations, community organisations or whatever we are going to call them are not pushed aside in favour of non-Indigenous community organisations just because they can provide better tender processes, which is often what occurs. We have a human services procurement policy in the Queensland government that has changed; we can go directly to select tender or tender processes for the best organisation. That is a new change. That is a process that has now been in place for just two years or so. I think it is important that Indigenous communities recognise that, where that has occurred, there are processes in place to try to remediate that.

I am not saying it does not happen, because I am aware of people constantly saying that that occurs. One of the difficulties is that governments often remain slightly inflexible about what they want to buy. If a government goes to an organisation and says, ‘We want to buy apples,’ and the organisation wants to sell them mangoes, they will go to somebody who wants to sell them apples. That is the sad reality. Government policy and procurement needs to catch up with what organisations can do. Queensland is attempting to do that.

—Thank you. That is very useful. My secretariat is warning us that we have run out of time, but the mention of Fitzroy Crossing inevitably caused me to think from my own perspective about the evidence that we received there concerning foetal alcohol syndrome. I am—mostly because of that evidence—aware that there is in fact a rising problem, and potentially an extraordinary problem, of mental illness as a consequence of that syndrome. I wonder two things: what you would like to say to us about that in general and also whether you are thinking of specific programs that may respond to this quite particular problem. The evidence that we got from those same women at Fitzroy Crossing was to suggest that we were faced with a possibly cataclysmic problem.

Dr Groves —I think the evidence we have before us in Queensland is no different. We recognise that this is probably the thing that is going to represent one of the greatest mental health issues for that next generation. There are two aspects: one is about preventing future problems—and that is an area that another part of the department looks at primarily. I cannot specifically comment on that because I do not know the full details. I am sure we could get that to the committee.

The issue that I think is the very disturbing one is that those kids who have foetal alcohol syndrome and who grow to be adolescents and young adults with considerable mental morbidity as a consequence represent a very great challenge to our services. It is something that is going to require, in my view, a combination of approach not only just from mental health services but from other disability support services because many times their disability support needs are greater than their acute mental health needs. I am not saying they do not have them, I am just saying they have both. Furthermore, there are a number of issues that Commonwealth government departments will need to get involved with as well.

It is not a simple answer. I believe a significant challenge for Indigenous people is when they have schizophrenia. The challenges of that psychotic disorder are very difficult for a whole community. Foetal alcohol syndrome, to me, is schizophrenia made worse; it is much more difficult, it is much more complex and it needs a much more coordinated approach from multiple departments across both levels of government. There is not an easy solution. But we need to look towards preventing it for the next generation.

CHAIR —Thank you both for giving us the benefit of your great experience. We are very grateful.

[2.48 pm]