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Community Affairs References Committee
06/07/2018
Accessibility and quality of mental health services in rural and remote Australia

AMOR, Mr Andrew, Chief Executive Officer, Milliya Rumurra Aboriginal Corporation

MALONE, Ms Sally Ann, Manager, Cyrenian House, Milliya Rumurra Outreach Team

McPHEE Mr Robert, Member, AHCWA Network, Aboriginal Health Council of Western Australia; Deputy Chief Executive Officer, Kimberley Aboriginal Medical Services

[16:17]

CHAIR: Can I just double check that each of you has been given information on parliamentary privilege and the protection of witnesses and evidence?

Mr McPhee : Yes.

CHAIR: I now invite each of you to make an opening statement if you so wish. We will then ask you lots of questions.

Mr McPhee : As I said, I'm here representing alcohol and drug services and, potentially, Milliya Rumurra but I do have more of a role regionally with a regional AOD committee. I have been involved in this same service for 20 years, and I've seen some of the changes along the way over those years. Looking at the terms of reference, I was interested in trying to get my head around what was really required in my opening statement. I look at it as three different factors: there are service factors, individual factors and the process.

In terms of looking at us as a service, we see a lot of mental health and social and emotional wellbeing issues amongst our clientele. The comorbidity between substance use and alcohol and other drugs is well known. Most of our clients that do present in our rehab facility present with some mild to moderate underlying mental health issue. Unfortunately, the service doesn't have the capacity to respond properly and appropriately to that. We rely on other outside agencies to provide some of that support. We just don't have the physical resources to deal with that.

In terms of where the needs should be, from my perspective we definitely have a gap where primary health services are not resourced enough or supported enough to deal with mental illness throughout the region. We definitely would like to be able to have the capacity to do that for the reasons I've just said.

In terms of individuals, when people come to our service usually we are the last resort for them. They have tried a lot of options, including trying to decrease or stop alcohol and drug use at home. It's very challenging for them. They're relying on family for support, which is even more challenging. They do seek support from other services without much success, so when they come to us they are pretty much psychologically distressed and oppressed. We then have to make sense of things. When we do look at the alcohol and drug issues, we can't look at that in isolation; we have to look at that with some of the other issues that are going on. One of the reasons why people, and I'm talking mostly Aboriginal people, who are a majority of our clientele, don't seek support for mental health issues is that it's about social and emotional wellbeing, and mental health issues are only one part of it. There are lots of other things that people have to deal with; it's not uncommon for us to deal with crises that arise.

Having said that, there are two basic issues I can see where people aren't accessing services as well as they should. As I just said, individually, it's because there are lots of things going on, and sometimes mental health issues aren't really a priority for people. In fact, with some people that we see it has become normalised within families and communities. The other issue is that alcohol and other drugs services are just not resourced properly, but other primary healthcare services are not properly resourced to deal with the problem either—especially the mild to moderate mental health issues that we see so commonly in the community, and particularly throughout AOD services.

Mr McPhee : By way of background, I might give you some information about KAMS. The Kimberley Aboriginal Medical Services is a regional peak Aboriginal community controlled health service. It's made up of seven members, and they are independently incorporated Aboriginal community controlled health services from across the Kimberley. They include BRAMS in Broome, DAHS in Derby, Yura Yungi in Halls Creek, the Ord Valley Aboriginal Health Service in Kununurra, the Bidyadanga community clinic just south of Broome, the Beagle Bay community clinic, and Nirrumbuk Environmental Health and Services. So we're a regional peak body, member based, and our role is to support our members in delivery of services at the front line and also to act in advocacy roles. We also own Kimberley Renal Services, which is a subsidiary company that delivers, on behalf of the WA government, renal health centres in Broome, Derby, Fitzroy Crossing and Kununurra. We also auspice the headspace youth mental health service here in Broome.

Within KAMS we have a social and emotional wellbeing team, and their role is to support the social and emotional wellbeing workforce across the Kimberley and also the AOD workforce and to deliver training to workers and community members in suicide prevention, and social and emotional wellbeing programs. I am also involved in the Kimberley Aboriginal suicide prevention trial. I am co-chairing the working group with the federal minister, Minister Wyatt, and I also chair the operational-level committee of that trial. I've got a pretty big opening statement, but I'll go through it; if there are any questions, you can ask me. I wanted to really think this through; this is an important hearing.

I just want to comment that if you put 'Kimberley suicide rates' into a search engine on the internet, you're going to get around 200,000 hits or places to go, depending on which browser you use. This is an issue that's talked about a lot. In 2015 an audit of Kimberley suicide data in The Medical Journal of Australia found that during the period 2005 to 2014 the suicide rate in the Kimberley was amongst the highest in the world. What this means is that Aboriginal family members in the Kimberley are losing loved ones at rates that are among the highest in the world, with suicide rates in certain Kimberley communities such as Balgo, Fitzroy Crossing, Mowanjum and Derby up to 20 times higher than the state average.

The Kimberley experience is that the trigger factors which contribute to suicide include those of alcohol and other drug use, relationship difficulties, family conflict or a previous suicide attempt. What is also understood in the Kimberley is that these trigger factors are generally linked and mask other causal issues, including intergenerational trauma, which the last group spoke a lot about; loss of culture; and other social determinants, such as employment, education, housing, racism and even discrimination. We know that these factors contribute to and underpin mental health and social and emotional wellbeing problems, and these problems permeate across all levels of life—the daily experiences and challenges that Aboriginal people in the Kimberley face in education, relationships, employment, social and family interactions, and other areas are all affected by and in turn impact on our mental health and social and emotional wellbeing.

One of the causes of the issues that we're facing in the Kimberley as I see it relates to the system itself. The Kimberley region is a large area and it's a complex area, but we have a lot of siloed service providers, particularly in mental health. Often the delivery models lead to individuals trying to navigate and manoeuvre across a range of service types. Depending on whether your needs are alcohol and drugs, domestic violence, sexual abuse, suicide ideation and so on, the individual has got to try and find the right service and navigate that, and often the feedback we've heard throughout the work that we've done around the trial is that people get very frustrated because they're often pushed to the next service provider and they don't actually get a service delivered in the end. So individuals become frustrated and confused and ultimately drop out. They no longer try to get the support, because it's really difficult to get.

Another issue as I see it is the acute need versus the community based services. I think there's a real imbalance, and I think this has been talked about a lot in previous reports. Under the WA Mental Health, Alcohol and Other Drug Services Plan, a commitment was made to reform the mental health system, including by redirecting investment from the costly acute or hospital-end services towards addressing the urgent need for investment in community based prevention and intervention services. The experience here in the Kimberley is that there's an increasing trend away from intervention and prevention, and community based mental health models. The state budget shows that there's been an increased investment since 2015 in acute and subacute mental health hospital beds and in alcohol and other drug treatment beds. And that's not to say that that investment isn't needed, but we continue to see a lot of money being put into the acute end and very little into the mild to moderate end, which is often where you've mostly got the needs. Despite the claims that that mental health plan would look for an optimal mix of services, there continues to be that imbalance. We need to find a way to address that imbalance, particularly in rural and remote areas.

I want to talk about what I see as part of the solution, and that's is that we need to look at ways in which we can strengthen the Aboriginal primary mental healthcare system in the Kimberley through Aboriginal community controlled services. I think that to date we can see that the current approaches are not working and that where we have communities delivering services you get much more effective outcomes.

What we see as a need is having a qualified Aboriginal mental health workforce within Aboriginal community controlled health services, such as AMSs and organisations like Milliya Rumurra. We need to have comprehensive, culturally responsive and appropriate mental health services for Aboriginal people in the Kimberley. It will result in reduced hospital admissions, by those workers working at the local level doing early intervention, prevention and helping to keep people out of the acute system. It will build local Aboriginal community capacity and resilience through workers been trained and people feeling much more comfortable in dealing with their own community. It will improve access and coordination of care by having one-stop shops, so people don't have to try and navigate this complex system. It'll help increase cultural awareness and cultural safety of mainstream programs, because these workers can work with the mainstream services to make sure that their programs and services are appropriate. And it'll reduce costs of service delivery at the acute end if we can keep people healthy and out of the expensive hospital system.

As background, I think the statistics that I mentioned earlier should be a concern and we need to take action. There have been many reports written about this. I hope that this Senate inquiry doesn't result in another report that doesn't actually go anywhere. Over the last 10 years there have been around 50 reports on suicide and mental health issues in the Kimberley where we've explored, investigated, recommended, discussed and identified all of the issues that we're dealing with. There have been at least two coroner inquests. There's been a youth suicide report and various other ones throughout the time. There are a lot of gatherings, forums, meetings and inquiries and we need to make sure that each one of those reports say that this is going to be different.

Now it is time for change. We need to take action. What we've found is that often nothing changes, or it's very slow in changing. We need to make sure that those good intentions, and all the work that's been done through all of the consultations, result in action. We need to start to implement the stuff that we already know. The learnings from the message stick report, which I think was released last year, had a suite of recommendations that we need to start to act upon.

I also want to acknowledge that there is evidence of some change and it's not to say that nothing has changed. But, I think, to tolerate only incremental changes is not good enough. Lives continue to be lost, not only through suicide but also through the despair experienced by Aboriginal families, friends and communities across the region. We need to make sure that that's addressed through equitable access to services that are culturally appropriate and embedded in Aboriginal community controlled services.

I might leave it there. I've got some other things I'll probably bring up along the way.

CHAIR: That would be appreciated, in terms of bringing them up further along the way. I'm wondering if you could table what you've—

Mr McPhee : Yes. I'll submit this. It's a submission that will go into the—

CHAIR: That'd be fantastic. Thank you.

Ms Malone : I have lived and worked in the Kimberley for 18 years in state mental health. I did have two years down in DCP down south, but I've been in my current role for six years. I am less of the voice of the management and coordination side; I am a manager of a service, but I also carry a clinical caseload—quite a large one—and our client caseload is 95 per cent Indigenous. I don't have a prepared statement because I got back from remote communities last night.

Senator O'NEILL: That's probably good preparation!

Ms Malone : I was speaking with the consumers, our clients, families of our clients, families of the bereaved. I don't have anything prepared, but I will be submitting a something in writing later down the track, if that's okay.

CHAIR: Yes, it certainly is.

Ms Malone : I've certainly worked with and observed a lot of the barriers that people have described today. I absolutely concur with everything the other two gentlemen have said. There is a range of barriers and there is a range of issues. Some of the service issues and system issues are things like coordination. I've heard the term 'silos' used a lot today, but I think there's an issue, too, with coordination and overcoordination. There are lots of bodies that position themselves as a coordination body, and as a small service provider we're not quite sure to whom we answer in terms of accounting for ourselves.

One of the things that we've started doing just off our own bat is accounting to the communities that we serve. I send a written report to the governing councils of each community every month, outlining the problems that we're seeing, the activities that we've got planned, results of anything that we've done and any help that we need from them, and I always ask for feedback from them. We've found that just that simple thing has really improved our relationship with the communities. All of the communities know who we are and who our staff are. Considering that I'm one of the non-Indigenous managers that have been referred to today, something like 40 per cent of our clients that we see on the communities are self-referred. The other sources of referral that we get are largely corrective services, child protection, mental health and the community clinics. We have a good relationship with the community clinics. That's really enabled us to get some reach into community.

Later on, after the other gentleman have spoken, I'll give a few quick notes speaking to each of the terms of reference. I just want to speak to some of the points I've picked up from Mr Amor. He said that rehab is often a last resort for our client group and, as you said, a lot of them have co-occurring mental health issues. But I think it also warrants saying that very few people get it right the first time. The rehabilitation and recovery process takes years, and people learn each time they go through the cycle. It's not something that is achieved in one admission to treatment. The other thing is that our service has worked with some of the families that we work with for two, three or four years; we know that we're not going to get it all done in seven sessions of counselling.

Through that process there are some families we've worked with where, after initially taking one person, we've ended up getting in several members of the family because, as anyone in the recovery game will tell you, sending people back to the environment they came from where there's been no change is just setting them up for failure. So we have had several families where we've seen significant improvements through working with the whole family. We have different individual plans for each person, but a whole-of-family dynamic. There is a process that we've developed for each family where they all agree what they're all working towards. We've especially found that getting the senior people involved and committed to change quite often has a significant effect on the younger ones as well.

As a drug and alcohol outreach service, we are a conduit for linking people up to other services that they need. So whilst we try and support people in community while they're waiting for rehab or whatever, we will continue to do the counselling or whatever support is needed. We don't just do counselling; we sometimes do crisis intervention, information and education. We don't necessarily work with the drug users themselves but with their families.

One of the things that we've found is that there are some massive program gaps up this way. We find that we are getting referrals for people who are discharged from prison—sex offenders who didn't get a sex offender program in prison because they weren't eligible due to the system rule that they have to get a sentence of 12 months or longer—and go back to the community that they came from. There are no sex offender treatment programs that I know of in the Kimberley. We're getting referrals because someone admitted to the person doing the assessment that they smoked marijuana three years ago. On that basis we'll get someone referred for counselling, but we're not resourced to do that work. It's the same with anger management and relationship counselling. Those are program gaps that we're funding through our back door because there might be alcohol or drugs in the mix. Those are some serious program gaps that I would like to see taken up in as realistic and holistic ways as possible.

Mental health services, along with drug and alcohol services in the outreach space, operate from a hub-and-spoke model. That is, they are located in a town and they go out to various communities that they service. There's a lot written about the limitations of that model. I'd be really interested to hear anything more about developments for place based services, but I think the community clinics are very much positioned to take on that place based role. There's a real opportunity missed by not having services beefed up in the communities. I will leave it there and will speak again later.

CHAIR: I'm sure more information will come out in questions.

Senator O'NEILL: You were here for the evidence that we heard this morning. One of the really significant things that are happening around the country is the suicide prevention trials. There are opportunities for changes of practice—not necessarily doing all the things that we were describing about the gaps that exist for mental health more broadly but, in particular, with regard to suicide prevention. I want to hear that it's going fantastically, but our evidence earlier today was quite negative about the success of that project to date. I just want to give you an opportunity to put on the record your view about where things are up to with the Kimberley Suicide Prevention Working Group and implementation.

Mr McPhee : I'm happy to speak given I am heavily involved in it. One of the things that have been really challenging with the suicide prevention trial is that it's an investment of $1 million a year over four years.

Senator O'NEILL: It is now.

Mr McPhee : Over four years now—yes.

Senator O'NEILL: We went back and fought very hard for that extra year for you.

Mr McPhee : Thank you. In reality, all the evidence shows that high rates of suicide are the result of an unhealthy community. If you look at indigenous populations around the world you can see high suicide rates, so that kind of unwell community is a result of colonisation, dispossession of land, loss of culture, loss of access to language and a lack of participation in the economy. It's all those social determinants of health. The reality is that, if we're going to do anything to make a difference, we've got to start to address those broader underlying issues. That's No. 1 and all the evidence says that. Trying to reduce rates of suicide when we know that's the backdrop is very difficult to do with a time limited and resource limited trial, and a trial that's got a requirement to approach suicide from a systems based approach. It's looking at evidence from Europe, which senses depression as the centre of why people take their lives, and all of the evidence in Aboriginal suicides says that it's not depression; it's often all of the other crap that you're dealing with every day.

Senator O'NEILL: Mr McPhee, are you telling me the problem with the trial is that the model is incompatible with the reality of Aboriginal and Torres Strait Islander people?

Mr McPhee : The problem with any trial that tries to address such a complex issue in a short amount of time and with a small amount of resources is that it's only ever going to be able to scratch the surface. What we've done through the trial is design a number of initiatives that look at a range of different parts of the system and trial them to see whether there are effective ways to improve parts of the system and build evidence around what works in Aboriginal suicide prevention.

Senator O'NEILL: Is that the main point of conflict that we're hearing here today: you're approaching the trial as a systems response model, and the community is saying, 'We don't want to do a systems response model; we need a cultural response model'?

Mr McPhee : No, that's not what I'm saying.

Senator O'NEILL: I'm trying to understand because they're talking about it in a very different way.

Mr McPhee : What the community is saying to us is, 'Until we fix those underlying issues, we need new housing, we need to get people into jobs, we need to ensure people have finished their education and we have to deal with the intergenerational trauma that's going on in people's lives.' They're the sorts of things that we need to address if we're going to reduce suicide rates. That's what I'm saying. What we're trying to do in the trial is build better evidence about the sorts of things that do work in Aboriginal community suicide prevention.

Senator O'NEILL: Are the community determining the types of trial experiences that they want to undertake, and are they in the room when decisions are being made about who gets money, because that's not what we've heard? We've just come from Derby, and there's disappointment there. I don't know that it relates particularly to suicide but I just want to put on the record that, in Halls Creek yesterday, we heard that people in Halls Creek who are on mental health medication are not getting their medication because it's not available to them. The nature of the problems in these communities and their sense of absence of control over what's being done to them are pretty palpable in the evidence we've received in the last 24 hours.

Mr McPhee : The trial has responded to the community by identifying nine sites: Broome, Fitzroy Crossing, Bidyadanga, the Dampier Peninsula, Halls Creek, the Kutjunka region, Kununurra and Wyndham. There are nine sites that have been identified. KAMS has been commissioned to employ a project coordinator to work with communities in each of those nine sites.

Senator O'NEILL: Do those project coordinators come from within the community?

Mr McPhee : One project coordinator, who's based here in Broome. They are working with each of those nine sites where we are appointing a community liaison officer to help bring the community together to identify a community-led suicide prevention activity that can be developed, implemented and evaluated within a 12-month period, within the trial time frame, to be able to build evidence around what works by engaging the community in coming up with solutions. There are nine community-driven projects that are being delivered across the Kimberley, including Derby, and we're working with the Derby suicide prevention network. There is frustration there, because the Derby suicide prevention network had requested funds that weren't within the confines of a systems based approach or within the budget parameters of one of the projects. Trying to split a million dollars across nine sites doesn't leave a lot of money.

So we've had to try and design a project that will work for Derby. They've come up with about two or three ideas, and the idea is that we'll go away, write them up into more detail, go back to the community working group and then they'll choose the final project and they'll be involved in its implementation. A community liaison officer will be employed for 10 hours a week to help locally, to implement that project, and that'll be a local Aboriginal person. Then, at the end of the 12 months, a full evaluation will be done and will form part of the trial evaluation to show what does work or what we learnt from that process. It's a trial. That's the nature of it; it's a trial. We're implementing a trial. What we had to come to terms with very early in the process was that this is not a direct tool to address suicide in the Kimberley. It's an opportunity for us to trial innovative approaches and evaluate them, and that's what we've had to deal with.

CHAIR: You said a million dollars doesn't go very far when it's divided by nine. I can't help but have the sense that by the time you've employed somebody for 10 hours a week—which is a relatively small amount of time—and in the scheme of things, with the amount of money that's available over that year, by the time you ramp up the project—I'm questioning the value of the nine sites. I'm not for one minute saying that they don't need the projects there. How did you work out whether the money that's available when you split it into nine is actually going to achieve results in a relatively small amount of time? How confident are you that you're going to actually be able to get measurable results, given the context that everybody has been articulating, which is that you're not going to build houses and deal with the overcrowding in that time? All those systemic issues that everybody's been articulating are not going to be able to be addressed. There are pretty significant issues that you're going to have to deal with, and it's a pretty steep task you've given people to do in that 12 months. I'm not saying you personally; I mean the project, sorry.

Mr McPhee : The site that's probably the most mature and ready to go is the Broome site. They've identified their project, which has a campaign approach. They want to develop and promote a life promotion message amongst the community of Broome. They're really excited about this project. We have got a working group of about 15 community members who are completely committed to this. So they want to develop local resources and identify ambassadors who can be promoted through radio and social media. They want to pay people casually to go into schools and youth centres to talk about life promotion messages and why it's important to look after your mental health, to seek help and to continue to focus on the positive parts of your life. That group is really excited about the project. They've designed it and they've identified it. They'll be able to run it for 12 months. What we hope is that if we can identify things like that that work and that we've been able to demonstrate through proper evaluation and evidence then we have the ability to go back to government and say: 'This needs to continue. This has been an effective way of doing things, and this community wants to continue to do this.'

Senator O'NEILL: Can I raise a concern about a four-year project that has a two-year lead time, a one-year implementation and then a one-year review period. Four years of funding have gone into one year of intervention.

Mr McPhee : No. The community projects are one element of the trial. There are also a range of other things that are going on at the same time. It's a systems based approach. There is work going on to train GPs and work in clinics to be better prepared to receive and deal with people who might have self-harmed or be suicidal. These are all elements of what the systems based approach is. There's work being done to develop a Kimberley-wide campaign to promote mental health messages to everybody, and where to go to get help and how to keep an eye out for others. There's also our youth peer-to-peer mentoring project, where we're looking to bring in young people from across the Kimberley to participate in youth mental health delivered by a young Aboriginal person, and for them to go back into their communities and deliver that youth mental health program to other young people. So there are a whole range of elements that are a part of the trial. It's a systems based approach, so there are various system level activities going on.

Senator PRATT: Have you sought that people participating in these activities at a community level will be able to acquit that for their CDP participation?

Mr McPhee : We are working with CDP providers: Winun Ngari in Derby, Crikey here on the peninsula, and Bidyadanga. We're working very closely with them.

Senator PRATT: That doesn't quite answer my question. Does that acquit their participation if they work on those activities?

Mr McPhee : I don't know.

Senator O'NEILL: Have you asked them to do that?

Mr McPhee : Can I ask them to do that?

Senator PRATT: Have you asked them to do that?

Mr McPhee : No. I'm not coordinating the project. I've got a strategic operational planning role.

Senator PRATT: So you don't know if CDP participation in these programs will be a valid part of the CDP participation necessarily?

Mr McPhee : I don't know for sure, but one of the other sites that they're looking to implement is a project where a group of community people—they're targeting the CDP organisations to recruit those people—will participate in a four-week healing, empowerment and leadership program, and the graduates from that program will be CDP participants. So they're targeting the organisation to work with those guys that are on their books. They will do the four-week Kimberley Empowerment Healing and Leadership Program. The graduates will then form a group, and a brokerage fund will be set up to be able to identify small activities in the community that money can be invested in. It might be that an individual might have experienced something traumatic in their life and the family wants to take them bush for a weekend. They can apply to that brokerage fund.

CHAIR: Are you able to provide us with an up-to-date list of the different components of the approach? I think that would help us to understand the shape and how it fits together because we have heard bits and pieces but it's hard to get hold of and understand the full trial now, as it's being developed.

Mr McPhee : Absolutely. I think one of the challenges we've had with the trial and something that all governments need to recognise is that the work that's needed to develop a response or a plan to implement the trial has taken 12 to 18 months of community engagement, working group discussions, steering group discussions, visits across the community. We need to allow that kind of time for proper resourcing and planning to happen. For a trial to start and for us to be expected to deliver services from day one of that trial is unrealistic. We pushed very heavily for the trial to be extended because a lot of time was taken in just understanding: what does this look like and how do we address it? You don't have the answers when an announcement is made. You can't just immediately, on day one, start to implement the program. There was a lot of work in the design of it. I think that's a really important message that government needs to hear: you can't expect programs to design themselves; you need to allow for proper community engagement.

Senator O'NEILL: We heard from people here who are on your advisory board and they articulated how separate they feel from the process. They feel that decisions are being made absent of them, and things are being inflicted on them, which is clearly retraumatising and very concerning to have on record. Mr Sibosado described any questioning of the way things were progressing as bullying by the minister, which is extremely concerning to hear. Everybody is entitled to their perspective and these things are complex but there's a reality that's been described here on the public record that is concerning to me. So in the context of working together, what is the situation with the leadership of the Aboriginal elders in this process and contrast that with the management leadership, who have the power, because it looks like they feel like they've got none.

Mr McPhee : I'm happy to respond. That's extremely concerning. I share many of Marty's frustrations, particularly with the working group. The working group meets every three months and, between meetings, we don't hear from any of the working group members. So apart from the community reps who sit on that working group, the project coordinator goes through them to do any of the work in the community—so if they're from Fitzroy Crossing; they go through the Fitzroy Crossing rep. But one of the frustrations is that the working group meets every three months for three hours and it kind of listens and hears what we present to it and then it goes away and we never see it again for another three months. I'm trying to find a way we can actually get the working group to be much more proactive because it feels like the issue then is somebody else's rather than the working group coming together as a collective to address the issue. We've planned to look at holding a planning workshop with the working group at its next meeting to say: what are we doing as a working group? Because at the moment all it seems to be is a process where we present information and it's either agreed to or not, whereas the idea of bringing everybody together is that we design and work together to collectively address the issues around suicide, and I don't think it's been effective at doing that.

Senator PRATT: I just want to ask Mr Amor about whether you've had the opportunity to invest and expand over the years or what your strategic thinking is on where your service should be headed.

Mr Amor : Sure. One of the areas we've moved into is really about responding to what our clients have been telling us, and it also has its origins in just the way our health care system is set up based upon acute health care. Alcohol and other drugs are a chronic disease, a chronic relapsing condition. So we're now treating alcohol and other drugs like a chronic disease, which means we are offering more support to clients post intervention and post rehab. So what we're doing now is providing what we call continuing care, and we have a program rolled out right across the region called the Kimberley continuing care program. That program is to continually support clients and their families back in their normal environments for 39 weeks post rehab. They get a 13-week rehab—high intensity and short term—and then are supported back in the normal environment. We have two stages. We call it after-care, which is the first 13 weeks after rehab. That's the time that a lot of people are highly stressed and anxious about going back to their normal environments. As was previously mentioned, sometimes the stresses are still there in the community. Sometimes the perpetrators are still there in the community. So we need to provide support for people.

Senator PRATT: What does that support look like?

Mr Amor : That support looks like a team going out and travelling to the area. The team conducts what we call recovery capital assessments on clients in rehab. It may involve going to checkout and the normal environment and making contact with families. So the support there is around care plans that have been developed. There's one-to-one counselling, case management, social support and also recovery groups as well with that.

Senator PRATT: How is that funded?

Mr Amor : That's funded through the Primary Health Network—WAPHA in WA.

Senator O'NEILL: How else do you go out if you're unable to find your clients.

Mr Amor : That's an interesting question. It's a new program we've developed. It's not 'did not attend' or 'discharged against medical advice' it's a 'not at home' issue, so we call it the NAH. So there's a lot of that at the moment, but it really boils down to building the right rapport with the client and the family.

Senator O'NEILL: Is that possible if you're actually not in their community and not part of the culture? That's what we've been hearing: 'We're sick and tired of the churn of people coming through. People come out. They look for us. If we're not there, they go. They get paid. We still don't get the service.' That's the endemic problem with the system of going out, doing the care at a time that suits and withdrawing. So what do you leave in place in community? What do you train up in community to provide the alternative to a FIFO or DIDO service which is not available at the time of need.

Mr Amor : It is a gap in what we do. The other issue is around alcohol and other drugs.

Senator O'NEILL: Does that mean you don't do any—that there is no-one in community and, if they don't get you when you arrive, that's it: they don't get anything?

Mr Amor : Not our staff, no. Not in the community.

Senator O'NEILL: And there are no other services?

Mr Amor : There are. There are other services that we link in. In regard to mental health, as I mentioned in my opening statement, we contracted a mental health service, Boab Health Services, to provide the mild to moderate mental health interventions.

Senator O'NEILL: In each of the communities that you service or just this one?

Mr Amor : It's across the region. So this is region wide.

Senator O'NEILL: So this is at Halls Creek?

Mr Amor : Yes.

Senator O'NEILL: Is there one there?

Mr Amor : There is. We do have clients there.

Senator O'NEILL: Are they in the mental health unit?

Mr Amor : Not Boab Health, no. You might need to speak with the WA Country Health Service about that.

Senator O'NEILL: People said they won't go there.

Mr Amor : Yes.

Senator O'NEILL: The way I'm seeing it, coming with fresh eyes, is that there's a service. Yes, it's getting funded. Yes, it's been delivered—on the terms the deliverer wants to deliver it in. The community is not receiving it if they're not there at the time it suits the deliverer. There's no-one to hold their hand in between, and there's no empowering of school development going on in the community with Aboriginal people that they trust. I want to know if that is going on as part of the suicide prevention trial. And that's not to say anything about the quality of the work you do when you can find people. It seems to me a prolific and very dangerous system failure that's costing a lot of money with no outcome—potentially.

Mr Amor : Yes, potentially. Indicators with the program so far have been good and positive, and clients have engaged. Part of changing behaviours with alcohol and other drugs is that you need the internal motivation yourself to change. What happens is that there are plans developed for the clients whilst they're in rehab, and then there are individual plans that we call 'stay strong' plans. The worker will develop this with the person or the family, and then say, 'Next week when I come back to you, we will review them to see how you're going.' It's just little small steps. It's not about stopping drinking or drug taking altogether; it may be reducing on certain days or it may be spending more time with family. People need that responsibility. You can't hold their hands all the time. What you can do is try and upskill them with some things that they can use, such as developing skills in certain areas around conflict management and around dealing with peer pressure et cetera. As much as we'd like to be there every day, that's not the reality. We've got people as far as Balgo and Billiluna. These places are hard to get to. Yes, it would be nice to be resourced to have people based in those communities, but that's not the reality of it. At this point, it's probably not cost effective, because you're putting staff out there and resources where there aren't a lot of clients anyway.

Senator O'NEILL: There are staff out there who just need training—people who already live in community, who need it.

Mr McPhee : We deliver clinics in Balgo, Billiluna and Mulan. The Aboriginal medical service has clinics in remote communities across the Kimberley. We've got workforce there. This was my point earlier around resourcing the Aboriginal community controlled sector to be able to provide mental health and social and emotional wellbeing services. The way that the system works in Australia is that you're meant to go to your GP and tell them that something's wrong. You're meant to get a referral to a mental health specialist and you get 10 or 12 appointments. That just doesn't work in the Kimberley. Firstly, our GPs are often dealing with complex, co-morbidity chronic diseases, so they don't have time. They've got waiting times of three hours with people sitting in the waiting rooms. So their ability to assess somebody's mental health and then refer—they don't even know where to refer. Often, the services are so complex, or they come and go, that they don't know who they're referring to. People fall through the cracks. The system fails. The system completely fails. And that's what needs reform in the Kimberley: we need to find a way to ensure that when the people come into our clinics—because Andrew's clients do come and see a doctor if they need a bandage changed or something like that—we use that opportunity to provide a service right then and there. But we're just not resourced to do it. Our model of primary health care is holistic. It's meant to be the social issues—the things that are stopping you from getting healthy are the things that our clinic should be able to help with, but we just don't have the resources to do it.

CHAIR: Again, we've run out of time. Thank you very much for your time today. We very much appreciate it.

Ms Malone : Just to touch on that topic of the outreach model, our service visits the communities. We visit one community fortnightly, because it's only a two-hour drive each way. But that's still four hours on the road. Outreach visits are logistically difficult. You have to manage safety and you have to manage staff stress. We have got locating people down to a fine art, when people aren't on the community. Where possible, we link in with other service providers. We have a pretty comprehensive system of exchanging information with service providers and family. Over the years, we've built good relationships with family. We link in with people by telephone. We do telephone counselling. We can even do intakes over the telephone. We visit other communities along the Dampier Peninsula monthly. We spend three or four days of every month up there. And we link in with the schools and the clinics.

CHAIR: Ms Malone, I'm really sorry, but I'm going to have to ask you to stop there. Could you send us a submission on this?

Ms Malone : Sure. No worries.

CHAIR: It's just that we've run out of time. I'm actually finding what you are saying very, very interesting.

Senator O'NEILL: Really interesting.

CHAIR: Could you send us a submission, because it's really valuable for us to know that sort of information—how you are doing this.

Senator O'NEILL: Yes, what's actually going on in the background—because we're just seeing broken bits.

Ms Malone : We're the consumer interface, really. This is the management and coordination bit, and we're much lower down the food chain.

CHAIR: Yes. It would be very, very valuable for us to have that. Thank you.