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Community Affairs Legislation Committee
21/02/2012

BOFFA, Dr John Dominic, Public Health Medical Officer, Central Australian Aboriginal Congress

MAIDMENT, Ms Leshay, Deputy Chief Executive Officer, Central Australian Aboriginal Congress

CHAIR: As always, we welcome representatives of the Central Australian Aboriginal Congress to today's hearings. You have information on parliamentary privilege and you know where to get more of that. Would either or both of you like to make an opening statement? Then we will go to questions.

Ms Maidment : We have submitted our Rebuilding families paper, along with a covering letter which addresses the 'Stronger futures in the Northern Territory' discussion paper. I would just like to take the opportunity to make our claims. As the leading Aboriginal health service in Central Australia, we have always taken a balanced perspective on the intervention. We have committed to maximising the benefits of what the intervention has provided, particularly in the instance of the EHSDI and Alice Springs Transformation Plan funding. The investment in housing has been welcomed and will make a substantial difference, although it must be highlighted that there is still a massive public housing issue in Alice Springs. As a health service, we have maximised the opportunity to focus on our efforts to address the identified needs in the community in relation to health service delivery and have been able to make some substantial gains.

Congress is at a critical time, as there is a massive risk which we would like to make a priority in this session: the ongoing funds and investment beyond 30 June this year. We are in a vulnerable and high-risk situation. We have the community reliant on this continued investment and commitment to the investment into social determinants of health and essential services. The long-term investment is needed to gain the long-term sustainable outcomes beyond any intervention.

In terms of the future, the major omissions are strategies to reap long-term benefits through the investment in early childhood. We advocate strongly about early childhood and the gains that can be made through that. The amendments to the income management are supported as an optional income management approach rather than the original compulsory blanket approach. But it must be noted that this blanket approach that has been enforced previously seems to have created some damage across the region. In terms of the future, we are feeling somewhat disheartened, with both Close the Gap and stronger futures missing the comprehensive strategy investment in early childhood. We are pleased the government is retrieving the current NTER act, which will reshape some of the more problematic elements of the legislation.

I would just like to give some examples linking back to the claims about EHSDI and the Alice Springs Transformation Plan funding. Congress, along with the other essential services throughout the NT, have had 250 new health professionals employed in the Northern Territory. There has been an expansion in police capacity, trained teachers in various regions and the investment in housing all across the region. EHSDI has allowed us to invest in essential services—primary healthcare services. At congress we have employed social workers and GPs, and expanded our midwifery services and clinical services by way of Aboriginal health worker capacity, and we have employed cultural brokers and Aboriginal family support workers, just to name some of the examples. So a significant investment has been made, and the capacity building at congress and other services has been very well received and we have managed to make some substantial gains through that.

With the Alice Springs Transformation Plan funding, we have three programs that we have set up and run at congress: the Preschool Readiness Program, the Targeted Family Support Service and the Safe and Sober program. I just want to provide a little bit of information about those programs. The Preschool Readiness Program has been able to complete 180 child health checks with three- to four-year-olds, which is its core group, including developmental assessments. It has been liaising with parents and the education department to enrol kids in preschool. We have now managed to have 120 kids enrolled in preschool compared to 90, and that leaves a gap of about 40 kids who are now not enrolled. Within that group of 40 kids, we are working intensively with parents and children to introduce them into the school. So we are quite proud of that effort that we have made with that program.

The Targeted Family Support Service employs social workers and Aboriginal family support workers who work in a team on a family case management approach. To date, 60 per cent of the families have benefited from the program and seen improvements in things that they wanted to address, and we have had significant improvement in access via community referrals rather than through the department, as the original model was set up. We would like to see this type of wraparound holistic approach for families generically available across the Territory, because it supports people and keeps them away from the FaHCSIA referral processes.

Whilst we had challenges with establishing Safe and Sober, our treatment program, we now have a full complement of staff. Over 12 months we had 600 people in the community access the program, and currently 200 are actively engaged in the program. A stable team of therapists is working alongside Aboriginal AOD workers. It is essential to have access to a treatment service other than a restricted residential service.

Linking back to early childhood is the Commonwealth's investment in the universal rollout of the intensive home visitation program, the Australian Nurse Family Partnership Program, which is based on the old model from the US. We are running that program at congress, and we have now had families graduate from that program as huge successes. Although these are small numbers, we are confident we will have long-term benefits, and there is a lot of community acknowledgement of the significance of this program for families. We would like to advocate a universal rollout in the region, rather than just to our health service area of congress, for mothers.

Dr Boffa : At a broader policy level, I think the total investment in the intervention in the first place was around $300 million recurrent, not counting the housing investment. The case for not only maintaining that but also increasing it is overwhelming. In the health sector, the Northern Territory Aboriginal Health Forum has just signed off on the latest version of the core functions of primary health care. We can show that with $2,500 per person investment in remote Northern Territory, which is what we have thanks to EHSDI, we can deliver a certain level of services, which include antenatal care, chronic disease management and a whole range of things.

What that does not include is the home visitation program. It does not include any sort of family support service. Outside of Alice Springs, if it were not for the transformation plan adding to that, we would not have targeted family support or case management of families. It is not happening in other parts of the Territory. Home visitation is not happening. Social and emotional wellbeing service treatment for addictions is not happening in most parts of the Northern Territory. That is over and above that $2,500 per person investment, and that is costed out, so if we want to see those sorts of services across the Territory we need to expand the primary healthcare investment, not decrease it. The EHSDI investment was $50 million, and we are concerned that we are hearing that that investment is under threat. We know these are tough financial times, but that level of investment not only needs to be maintained but also needs to be increased.

In primary health care we can cost out what we need to make a difference, but the police, and all the other areas of investment, have to be maintained. If the Commonwealth state funding issues are such that you can get the Northern Territory government to pick up 40 per cent of the cost of the police, the teachers or some of the other funding, so be it, but the bottom line is that that level of investment has to be increased as we go forward, not decreased. I think that is vital to our long-term success. We are now talking about a 10-year plan, which is a good thing—we are not talking about an emergency response; we are talking about a 10-year investment—and the sorts of programs Leshay has highlighted, which congress has been fortunate enough to be able to deliver, are not happening in other parts of the Northern Territory. They took additional funding through the transformation plan, which is also not recurrent. It will be a real problem.

The best part, and the part of the response that has overwhelming support, is this investment. There are lots of issues and complexities around some of the legislative aspects and some of the ways we have distributed aspects of that, which you probably heard a lot about this morning, but the investment has to be maintained, and it is making a difference. The country can afford it. Even though we are in tough times, Australia's taxation revenue is only 30 per cent of GDP, which puts us third last in the OECD. Denmark's is 50 per cent and Canada's is 34 per cent. If we were just to increase our taxation revenue to the level of Canada, at 34 per cent, that would be an additional $16 billion recurrent. So we are not prepared to accept that the disadvantage Aboriginal people have cannot be properly invested in while the country is not prepared to create the revenue base it needs to make that investment. It is possible to create that revenue base and maintain a very stable and prosperous economy. We are seeing debates all the time around that, but it is not up to us to tell the Commonwealth government how they should get their funding. If they can make this investment within current levels of taxation, that is great. But we will certainly keep saying that there needs to be a very much increased investment on a recurrent basis and, if necessary, the Commonwealth government has the power to make sure taxation revenue is increased.

Senator SIEWERT: The programs currently funded all finish at the end of June. Is that correct? All those programs you just outlined, which are the programs not covered by the transformation funding—they finish at the end of June?

Ms Maidment : That is true for the Safe and Sober Program. We got one year of extra funding for the Preschool Readiness Program and for targeted family support. But, for the Safe and Sober Program, we do not have any committed funding beyond 1 July this year.

Dr Boffa : And all of the EHSDI positions—there are about 30 of those—finish. That plus Safe and Sober finish on 30 June. We already have staff in all of those positions. We are in February, but they are already starting to look for other work. We have not been able to guarantee employment beyond 30 June. No-one has left yet, but it is not just a case of finding out on 30 June—

Senator SIEWERT: No, because people start looking for jobs.

Dr Boffa : We were talking yesterday about retention of staff—this is critical.

Senator SIEWERT: Of the recurrent $300 million across all the programs, how much was for health?

Dr Boffa : For health there was $50 million recurrent, of which only $29 million has gone into primary healthcare services. Around $7 million has funded RAHC. Around $4 million to $5 million went into so-called hub services, which have not worked very well. In addition, a significant amount of money has gone into the regionalisation process. On top of that $50 million, another investment was made in the Sexual Assault Referral Centre, SARC. That was expanded into SARC-plus, which means that a service located in the population centres of Alice Springs and Darwin is now trying to address failure to thrive and child neglect in every community in the Northern Territory, through a fly-in fly-out model. That is getting a lot of money. That is getting $7 million or more.

Senator SIEWERT: Is that working well?

Dr Boffa : No, that is not working at all. It has been evaluated. That is one example of where money could be redirected and reinvested. On top of that, however, we still need substantially more money to deliver the core primary healthcare services across the Territory.

Senator SIEWERT: The easiest way to calculate it is $2,500 per person plus how much extra for the home visitation? How do you quantify that?

Dr Boffa : We are doing a detailed costing study now, but, if I were to hazard a guess, I would say that at $4,500 you would get everything. So another $2,000 per person times 55,000 people. You are talking about an extra $100 million. The current investment in primary health care in the NT is around $120 million. If you look at the investment in income management, that is of the order—

Senator SIEWERT: It is $250 million over the term. That is just the new one.

Dr Boffa : Yes, so this is not as much as the investment in income management. If you compare cost-effectiveness, I would say that investment in primary health care and in these sorts of programs will deliver a much greater return. Forget the arguments about whether it is or is not working in this community or that community—at a population level, the investment in primary health care is going to be a more effective use of resources. But we should not need to go there either. There should be enough funding to do both, if that is what the government wants to do. But we need to maintain a much bigger investment in primary health care to make the difference that is needed to close the gap—as well as investment in community safety, police and education. The original vision of a broad investment in the social determinant of health is what is needed to be maintained over 10 years and expanded.

Senator SIEWERT: The evaluation of SARC or SARC plus—

Dr Boffa : It is not publicly available but if you can get a copy of it and provide it to us we would be very pleased to—

Senator SIEWERT: That was going to be my next question. When was it finalised?

Dr Boffa : I think it probably finished about four months ago. It is very damning. It shows that for every position created in Alice Springs and for every attempt to see a family or a child they are unsuccessful about one in 10 times. They will travel out to remote communities for the purpose of working with the family and the children that are in difficulty and they will very rarely find the family there or be able to engage with them. I think it is a very inefficient use of resources.

Senator SIEWERT: Who is running those services?

Dr Boffa : It could be the Northern Territory health department or it might be an independent organisation; I am not sure. The sexual assault part of it is valuable and needs to be maintained. The expansion to then include the broader issue of child neglect and failure to thrive is the problem. There is a need for a specialist support service for sexual assault. It is not a huge need but it is an important service and when it does occur—although it is not common—that service is valuable. But then they expanded it to take over the role of the primary healthcare system. The primary healthcare system has to deal with child neglect and failure to thrive. That is its core business. But to do it properly they need family support and resources. You have to you be able to provide case management to families and that sort of thing, which does not exist. Nurses, doctors and health workers alone cannot effectively deal with high-need families that need support. You need social workers, Aboriginal family support workers and social and emotional wellbeing services as well. Because that is expensive, the cheap option was to fund the centralised fly-in fly-out model. But it is no substitute for on-the-ground community based core services in the primary healthcare sector.

Senator SIEWERT: I am sorry. I am again crossing over into the evidence you gave yesterday, which is on the public record if people want to see it. Yesterday we were talking about the holistic approach that in particular the congress has been taking to provide support and primary health care. Is the argument therefore that you should be putting into that mix those child neglect and failure to thrive—

Dr Boffa : Absolutely. They are core primary healthcare services. They have to be a part of it. With the economies of scale, you get better retention, better recruitment and better outcomes by putting that into the primary healthcare sector rather than having it as an add-on fly-in fly-out vertical program. But then the other problem of course and the reason why they opt for the fly-in fly-out is because you have to invest in housing and infrastructure for staff in remote communities, which has not happened. Housing investment came for community housing, which was very welcome and which is absolutely essential and needs to be increased. But lack of housing for staff has been a huge reason why some remote communities struggle to fill their funded positions.

Senator SIEWERT: Have you had any discussions about those programs being integrated better with your primary healthcare function, or anybody else's for that matter? Secondly, have you had any discussions with government about your funding proposals?

Ms Maidment : What was the first one, sorry?

Senator SIEWERT: Did you at the time or subsequently have any discussions with government about the need to integrate? Basically did you have the discussion we have just had with government?

Dr Boffa : Yes. We now have the Northern Territory Aboriginal Health Forum, which includes the Northern Territory government and the Commonwealth government. It has just signed off on a new version of the core primary healthcare services. The main reason for updating that was to include family support services, alcohol treatment services, early childhood services and mental health services. That has now been put in place and everyone has agreed that the optimal service model is what we are talking about here. It is just a matter of how to make it happen and how to not take shortcuts. In the absence of sufficient funding, we ended up funding centralised services that were fly-in fly-out but they are very inefficient and they do not achieve very much. This is why our 10-year plan has to be to get those services integrated and on the ground—not in 10 years but quicker than that.

Senator SIEWERT: I also want to follow up on the second question I asked which was around the funding. Dr Boffa, you said you are working on a refined funding process.

Dr Boffa : Yes. Now the core services have been updated, we want a costing study to properly cost it out again. We have done a costing previously, which is fairly useful but not good enough, so we are trying to look at how to fund that properly now.

Senator SCULLION: Dr Boffa, earlier in your submission you mentioned some health checks of early preschool—was that it?

Ms Maidment : Child health checks?

Senator SCULLION: Child health checks. When the child is checked and they have some presentation, about how long is it usually? I take it you will make a referral; as part of the health check, if there is some presentation that you know needs to be dealt with, there would be a referral. Do you have any idea of the times—you might want to take this on notice—between when the referral is made and when they can actually get to present again to somebody for treatment?

Ms Maidment : That would depend on what service they are after.

Dr Boffa : Within congress, we are in the fortunate position where most of the referrals can be made internally, so we are not reliant on external referrals agencies. For instance, the child health check could lead to a referral to our Targeted Family Support Service for case management of the family. It could lead to referral to the alcohol treatment program. It could lead to referral to our children's services program. We have the preschool program, where there is a child psychologist, so if there is a developmental problem then even that gets referred internally. No other service in the Territory has all that. Once they do a child health check and identify developmental delay or other problems, they are often reliant on outside referrals to special services which may or may not ever get to see that child. So those are again the benefits of having it all within the one organisation.

Senator SCULLION: Certainly during the estimates process we were provided with some evidence that, during the other rounds of the NTER health checks, it took, I think, between 12 and 15 months—this is only ear, nose and throat and dental—from the time of referral to actually seeking treatment.

Dr Boffa : Congress, when we put our proposal in, said we were not prepared to separate stage 1 and stage 2. We ran it jointly, downstairs and upstairs. The child health checks were happening downstairs, and if there was a need to refer to stage 2, which was the follow-up, that happened upstairs on the same day, at the same time. We never delayed it. A lot of services did the child health checks first and then they got funded to do stage 2 nine months or a year later, and finding the kids was a problem. It was not a good approach. We do not think it should ever happen like that again. There has been a very good evaluation of the child health checks done by an independent consulting group from New Zealand which has shown all the issues and concerns and how to do it properly in future. The future is integrating. Child health checks have to be a core function of all primary healthcare services in an ongoing way delivered every year, not as a one-off. I think that was the lesson learnt from that process.

Senator SCULLION: Again, this committee was given some evidence a little while ago that as part of the Australian Health Survey, on advice from the Australian Bureau of Statistics, Aboriginal children would not have some biomedical sampling taken, particularly blood samples. They gave a number of reasons, but there is some concern that there is going to be a large gap in the information. These are all voluntary. The next one to be taken is not going to be done for another seven years or something. What has been your experience in terms of those sorts of samples being taken in the right context—the family context? They are all doing it anyway.

Dr Boffa : I think the main issue that came up with that survey was the lateness with which the addition was made. The survey was consented to through NACCHO and all the rights processes, and then at five minutes to midnight they wanted to add the bit to children. I think there is quite a lot of support for that; it is just that it happened so late that I think it created complexities. But I think that if it is done again, and done properly, you would get the national support.

Senator BOYCE: The only trouble is that it is not being done until 2017-18.

Dr Boffa : No, so we have missed the opportunity. In child health check processes, if doctors recommend that children need to have a cholesterol check or have some of those biomedical things checked, it gets consented to and it gets done on a case-by-case basis. Unfortunately, now high cholesterol and various other metabolic issues are presenting earlier and earlier in some children. That gets picked up in routine child health checks if necessary blood tests are done and those tests are ordered. It is part of the normal delivery of quality child health checks.

Senator SCULLION: That throws some light on the reason. We were given another reason.

Dr Boffa : Were you? There is another story to that.

Senator BOYCE: We had evidence earlier today in regard to the lack of core and recurrent funding and the fact that a lot of funding in Aboriginal social and health services is done through six-month grants are whatever, with organisations having to report multiple times. And a lot of funding goes to large not-for-profits that do not have experience in the area. Could you talk a little bit about both those sorts of situations and how they affect the work that you do in primary health.

Dr Boffa : If we separate the OATSIH from other money—and it is important to do that, because the OATSIH budget is now more than $1 billion recurrent—prior to the transfer of health funding in 1995, ATSIC had $52 million for primary healthcare services. There has been a massive expansion in funding. Of that money, only about $300 million to $350 million of it goes into community and child primary health care. But that money is long term. The primary healthcare sector is a big fortunate compared to some of the other sectors working in Aboriginal communities.

Senator BOYCE: But there is an overlap between welfare and health provision.

Dr Boffa : We get some significant core money that is long term. But on top of that there is all this new money that could, if it was allocated properly, deliver. There is enough money coming into the Northern Territory to give you $4,500 per person if the mental health money, the AAD money, the family support money and the early childhood money that is coming in was allocated according to need and funded core services. We do not need more money; we need to spend what is there better. But that money gets tendered out. It does not go through a needs planning process through the forum or any other structure. It gets tendered out. Then you get all these new private providers coming in providing little aspects of things. You then get a fragmented service system, which does not deliver good outcomes. The problem that we have is that there has been quite a good planned approach to some of the primary healthcare core resources, which get money for a long period of time. That is a lot better than where we are pre the transfer of health funding, when everything was short term. But a lot of the new money that has come in has come in through mainstream departments such as FaHCSIA and DoHA and not through OATSIH. That money has been tendered out and has not been used in the most efficient and effective manner.

CHAIR: Thank you very much, as always, to the Central Australian Aboriginal Congress. I am sure that we will see you again.