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Community Affairs References Committee
05/07/2018
Accessibility and quality of mental health services in rural and remote Australia

TRUST, Dr Stephanie Karen, Principal GP, Kununurra Medical

[09:52]

CHAIR: Welcome. Before we start, can I double-check that you've been given information on parliamentary privilege and the protection of witnesses and evidence?

Dr Trust : Yes.

CHAIR: Fabulous. I now invite you to make an opening statement and then, as you probably just heard, we will ask you lots of questions.

Dr Trust : I don't really have an opening statement, except to say that I have worked as an Aboriginal health worker, nurse or GP in the area for about 30 years across lots of different parts of the Kimberley, but also down in Perth and across in Queensland. Over those years I've seen some improvement in mental health services and accessibility to what is provided, but we've got a long way to go. No doubt you've seen the statistics that we have in the Kimberley.

CHAIR: Yes. GPs are often the frontline of mental health support. In your practice, how prevalent is mental ill health or people coming in to seek help for their mental health?

Dr Trust : We could probably pull stats on diagnosis out of our system, but in terms of being a GP working today—I'm working today, of course—at least one-third, and some days even half, of the patients that I'm seeing in the clinic where I work, which is a general GP practice, are dealing with some level of mental ill health. Whether that's something that's mild that I need to at least give some support for, or whether that's something a little bit more moderate or even severe, where I need to get the state health team involved, it's a significant amount of what I see every day. When I talk to the other three GPs that I work with, I find their experiences are very similar. And the age of these patients can range from children right through to the elderly.

CHAIR: So you're seeing the full range?

Dr Trust : We do, yes.

CHAIR: The issues that you are addressing with the people who are coming in for that support, are they similar to what our previous witnesses were talking about, such as the impacts of intergenerational trauma, drug and alcohol abuse? Are those some of the major triggers for people's ill health?

Dr Trust : Yes, absolutely; definitely intergenerational trauma. We also see abuse of different types, including sexual abuse. In some ways it's a whole breakdown of cultural values, cultural connections, that we see; it's all absolutely contributing to that.

CHAIR: Could you give us a quick overview of the general practice services that are available in Kununurra and the region of the East Kimberley?

Dr Trust : Sure. Wyndham has a hospital, so essentially if you want anything acute seen by the services there, it's through the hospital. If it's non-acute, you have organisations like Boab Health—I'm not sure if Simon spoke about Boab Health service, but it does provide psychological support—Anglicare and the Kimberley Mental Health and Drug Service. These do provide services across the East Kimberley, so they would travel to those centres but they're not based there. That would be very similar for Wyndham and Fitzroy Crossing.

In Halls Creek, Kununurra, Derby and Broome there is an Aboriginal medical service in each of those centres. In the East Kimberley, Kununurra Medical is Aboriginal owned, but we're a private GP practice. We're the only one between Katherine and Broome, so we see a wide variety of people coming in from all over the region and from stations, including people from across the border. In terms of GP services on the ground, it can be really quite hard for lots of patients.

In Derby and Halls Creek, you've got an Aboriginal medical service and a hospital providing care in those centres. In Broome, you've got other services. I think there are about four GP services, as well as BRAMS—the Broome Regional Aboriginal Medical Service—and then the hospital. The Kimberley Mental Health and Drug Service are based in Broome as well. They have an inpatient unit in Broome.

CHAIR: Yes, and they have some services here too, don't they?

Dr Trust : They do, yes.

CHAIR: We're catching up with them in Broome. What is your view on the adequacy of the mental health services and the support services in the East Kimberley?

Dr Trust : They are a little bit better compared to 30 years ago, but still what we have is—essentially, if I'm looking for someone who needs to provide some type of mild to moderate support, psychological counselling and support, in Wyndham there's no-one one except the visiting service. In Kununurra, we have one private psychologist doing some time after hours, after he finishes his day job, which is at about 4.30. Up until a month ago we had another private psychologist in town, but she has left. Besides that, we would have to access services at Boab Health service. I think my last email told me that my patient would have a four- to six-week wait at least. At Anglicare, if I ring and talk to someone I can often get a patient seen within a week, but that's very much dependent on staffing. There is a high turnover of staff in quite a few these organisations, which, again, is a criticism that lots of patients come in with, because they don't want to keep telling their story.

I'm in psychiatry services. The Kimberley Mental Health And Drug Service has a regional psychiatrist. He visits fairly regularly. By that, I mean every three to four weeks. We've started a clinic at the practice where we can actually get patients seen so that we can try to destigmatise some of the appointments.

CHAIR: How often do they come there?

Dr Trust : Every month.

CHAIR: So you've got someone coming for how long every month?

Dr Trust : A session—so a morning.

CHAIR: They're based there from a morning session.

Dr Trust : Yes, at the clinic. That's a brand-new service that we're trying to start, to see if that makes a difference.

Senator O'NEILL: At least it's at the clinic, so you're not going somewhere special.

Dr Trust : That's exactly right.

CHAIR: So stigma is an issue.

Dr Trust : Yes. Everyone knows, if you're going to the back of the hospital, what that's about. The other thing we've started doing, probably about 12 months ago now, is telepsychiatry services. We're doing those with a psychiatrist—he's actually based in Queensland—for reviews of mild to moderate cases. It's managed by the GP, with a little bit of support. He's been quite invaluable in providing these services.

CHAIR: In terms of the telehealth, is that starting to use the new Medicare item?

Dr Trust : Yes.

CHAIR: Four of those sessions have to be face to face. If your telehealthing—is that the right word?—into Queensland, how has the face-to-face service been?

Dr Trust : That's difficult, and that's always going to be difficult, no matter what, because anywhere you telepsychiatry to—even if it's Perth or Darwin—you're going to have to try to see if you can get a patient there. That's extremely hard to do. Often, what we're doing is trying to manage the patient on the two or three visits, so we're really quite careful on who we refer to that service.

CHAIR: Does that mean managing when you would try to balance the face-to-face service with the morning in the clinic, even though it's a different practitioner?

Dr Trust : That's right. That's exactly what we have to do.

CHAIR: I suppose, given that you've only just started it, you don't know how that's going to work yet. Would that be a fair assessment?

Dr Trust : Yes, absolutely.

Senator O'NEILL: I want to ask about the client relationship. Does your patient then see perhaps that they have a team? They've got their doctor that they see, but they have their psychiatrist. Does it operate as a team care unit?

Dr Trust : We do. Often, with the telehealth sessions, the GP, and sometimes the counsellor on the ground, will be in the room for a part of the consult, especially towards the end of the consult. So there'll be two of you in the room with the patient, and the specialist's on telehealth.

Senator O'NEILL: It strikes me that you're a bit of a goldmine, you're a bit of a find, Dr Trust. Are you a local elder?

Dr Trust : I don't think I'm an elder, but I'm a local.

Senator O'NEILL: So you've been in the area. Is this your country?

Dr Trust : I grew up in Halls Creek and Wyndham. I'm Kija, which is the next tribe over from Miriwoong Gajerrong. That's the country we're on at the moment.

Senator O'NEILL: I pay my respects to you. I really think that it's very valuable for us to have your experience on the record here, because, sadly, there seems to be a preponderance of need in health care in the local First Nations communities. But, while that need is there, there's actually a capacity, I think, within the community to find people who want to help others. I asked a couple of questions about identifying resilient people who are doing unpaid work in their communities. Is there a resource there that we need to more carefully gather and properly train, fund and support so that we can start to build capacity within these communities for healing with deep cultural knowledge, not an immersion experience in cultural knowledge? I'm really interested in your thoughts about the asset base that's here and the solutions that are within communities. I just invite you to offer up your wisdom on those things.

Dr Trust : I think absolutely. What we've been talking about so far is what is walking in the door clinically in terms of the GP but, of course, there's a whole level of trauma on the ground, a whole lot of empowerment and resilience we need to build in our kids on the ground. For me, mental health shouldn't be a stand-alone program. What I'm trying and what I'm teaching my staff to do is actually sprinkle it through everything. I'll give you an example. We have got a few other organisations that have won contracts for road building. We do all the pre-employment medicals. Part of that is we change the way we do it and do a little bit of industrial medicine to actually increase and look at that resilience in those mainly young Aboriginal men, who are a group we don't get to see walking in the door very often.

Senator O'NEILL: Do they come in because they have to comply with that to get the job, so you've actually got a point of contact?

Dr Trust : Yes, absolutely. We work with them and the employer to be able to get them fit and well enough, including their social emotional wellbeing, to be able to do the job but then we support them as they go along. If you talked to the guys, they don't think they are coming in for a social and emotional wellbeing check; they're coming in for their medical, which is what every other guy does when they're coming in for a check-up. But it's about starting to think more broadly about where you sprinkle this empowerment and this resilience. There's a fantastic program called the KELP program. It's run through KAMSC, the Kimberley Aboriginal Medical Service Council. I think one of the local organisations here run it on the ground and that's a program aimed trying to get people to build resilience and empowerment. For me, that type of program should be something that all our young people are doing. We are really trying to get people to look at some of the things they can do to improve and empower themselves and build resilience but also then how to look for help and get help when they need help.

Senator O'NEILL: So that's a point-of-contact opportunity that arises. In communities, particularly remote communities where we know that transport is a big problem in terms of going to services, there are also cultural capacities and just gifted people who are natural healers in their own way, from their disposition. How much of a resource of that kind exists in remote communities across the Kimberley region? What sorts of structures would need to be in place to begin to empower those people to develop skills in informal and formal ways to turn them into a few more Doctor Trusts 30 years down the track?

Dr Trust : I think you're absolutely right. If you talk to any of the big families in the Kimberley, there's always one or two people that stand out from those families. Those people especially need support because often they're the strong ones in the family. And I guess there's a fine line between empowering them but also not setting those people up to then be the person that takes everything on. So it has to be done in a way that's sensitive and understands that. But, absolutely, often those are the people that I'll see regularly in my clinic over the years because part of my job is to help those people on the ground. How do we formalise that?

Senator O'NEILL: Is there no point in formalising it or is it working as it is? I don't want to bring my expectations about how we lift that if it's not going to need a lift. Is it culturally appropriate? Is it a resource? Would it be subject to exploitation if we started to formalise it?

Dr Trust : I don't think so. It is something we definitely have to look at. And it's something that we should support. I don't pretend to know the answers and how we might do that. But the answer to your question is yes. I think getting those people together and having a way of being able to support them and give them some formal ways of being able to deal with some of things they have to deal with—because often they have no formal training in anything—and to support them in their own resilience. Them knowing exactly who around them can help them is something we should definitely look at. A part of this empowerment program that I've talked about is that people from that program then step up and can become trainers in their own right. The idea was that those people are generally the people we're talking about, and then this network of people starts happening, and you can ring each other and support each other.

Senator O'NEILL: How often are people doing that very important role unpaid?

Dr Trust : Every day right now.

Senator O'NEILL: So there's a skill set and a capacity there that is not being acknowledged and not being funded, so nobody in the community sees what those people are doing as having practical dollar value or as a job that they could be doing in their community. So that sort of organic version of health care is actually not being funded in any way in the community?

Dr Trust : No.

Senator O'NEILL: Would it be a mistake to try to do something like that? What would be the unintended consequences of such an effort?

Dr Trust : I think the unintended consequence is what I said before, where you potentially then get people that you overload even more.

Senator O'NEILL: There needs to be a team kind of response?

Dr Trust : Yes, it needs to be a team. I think there needs to be some thought about how we'd roll that out. There are some natural things happening in the community already. There is the program I talked about. The other thing is Aboriginal health worker training. Often they're the ones where we might suggest you go and do some of that training and bring that. There are quite a few people who've done that training and don't work in that field but often then do that role in the community unpaid. I think it's something that absolutely merits looking at and going forward with.

For example, I've got a cousin in Halls Creek. We talked about young people in distress and the number of young people in distress who attend emergency departments. Often the attendance is after hours when everyone's closed. There are criteria you follow in ED, and if you don't meet them then you'll be back home. But what do we do with these kids? Sitting in a group and having a cup of tea with a family in Halls Creek, the thought was: maybe we should look at a list of people who are happy for you to ring them. You might have to go through a list of 10 to find the person who's in town and can come in and sit and talk to that person, but it's that whole thing about someone coming in, sitting in with that young person and having a conversation. I think there's a community in the Northern Territory where someone took the lead and did that in their community, which reduced the number of suicides in their community. So there's a real need to do that and to have some way of being able to formalise those networks, use them in a way that actually brings people and supports what's already trying to happen on the ground, and then follow these kids up over time.

CHAIR: There are a couple of follow-ups from there. One is the issues around ER. We've heard in other places as well that ER is just not suitable for people who are turning up with very significant mental illness. Does that happen here?

Dr Trust : Yes.

CHAIR: Secondly, we've also heard that there should be mental health nurses, for example, in ERs to assist. My last question is that, while I suppose I agree that there are people in communities who are the people everyone always goes to, I'd be reluctant to support that in an ongoing way without doing it properly, because I think you're going to end up with even more stress on the people who, as you've said, are the go-to people. But then it is properly acknowledging that that form of support is urgently needed and then providing the funding and training for people who have the interest, so it's much more formal and basically people are recognised for the work that they're doing. It is part of delivering mental health support and social and emotional wellbeing—picking up on what you were just saying—but providing it in a much more formalised network so it's a recognised role for people with the work that they are doing in supporting community, and also not just relying, as you've just articulated, on one or two people who are always the go-to people. I could name a whole lot of people, in a lot of communities that I'm aware of, who are those go-to people whom everybody is always turning to for help.

Dr Trust : Absolutely. That's exactly my concern. All of us, because we all live in a kinship system, do that work after hours, after our paid jobs anyway, and I can say that for myself. Instead of having nurses in ED, why don't we have Aboriginal health workers who are trained in social and emotional wellbeing who work shift work and get paid? That's been a fight we've been having here for many years, in terms of being able to improve that, have people on shift work and incorporate them into the services we already provide.

Senator O'NEILL: I want to ask a question about suicide ideation, suicide attempts and response capacity. It's out of area, but I visited—I won't say where, because I don't want anybody to be identified—a remote community west of here. I met two burly policemen who were clearly very distressed by having recently just got there in time to cut down a 12-year-old girl who'd attempted suicide. They spoke in such despairing terms about, having got her into town to the emergency, her getting some burn cream and being back in the community the next day. That was it. There was no support. What needs to happen in those situations? We've heard a little bit from the guys before you about step-down care and support. Their despair was that she was back without support. The other issue that Senator Dodson has raised with us—and the reason we're going to Derby and we're also going to a work camp—is that when mental health care fails, too many First Nations people simply end up in the juvenile justice and jail systems. I'm keen to get your response to that suite of problems.

Dr Trust : I see quite a few. I think we're absolutely inadequately dealing with mental health patients, social and emotional wellbeing patients, in emergency departments. No matter where you go there are policies in place. No doubt when you talk to the people who are in charge, people are following policies—and kids have to be followed up the next day. No doubt they have those policies in place, but they're still failing for whatever reason.

I've had the same frustration. I have had someone see me—and where I work is attached to the hospital—and say that they're going to kill themselves. I got them into emergency and then when I was driving home from work I passed them walking back home. It is something that we desperately need to look at in emergency departments—and it would be wider than the Kimberley, no doubt. We need to look at how we handle it. The numbers of people presenting to emergency departments—even the tertiary ones in Perth I used to work in—are just going up and up, especially if you mix in drugs and alcohol and the issues that come with that when young people are presenting. Of course, you have to protect staff. There are quite a few more assaults and things happening in the ED as well. We do have to find a way so that people are being either managed or, if they're going home, managed and followed up in the community. But the reality is that we just don't have the staff often to do it.

Senator O'NEILL: So we've got a suicide level that's increasing and youth suicide in particular has had a terrible increase. The kids who don't complete death by suicide and have a drug and alcohol problem can get caught up in a cycle of crime et cetera. How many of them are ending up in juvenile justice? Is there a link between mental and social ill health and the juvenile justice and prison systems?

Dr Trust : Absolutely.

Senator O'NEILL: Tell me about that.

Dr Trust : You've got young people who are traumatised for whatever reason growing up and not getting access to services. Our mental health youth support services in Kununurra are just abysmal, and we're the regional centre so anywhere outside of Kununurra is even worse than us. I saw a 14-year-old this morning who has been to two different organisations and seen five different counsellors about what happened to her when she was younger. She has now given up and is refusing to go to anymore because she's sick of seeing different people. She is not going to school and is now starting to drink, take drugs and have antisocial behaviour. If we don't stop that, she will end up in juvenile detention. So that's just the time line. I see that every day. So absolutely there's a link, and we do need to look at what we can do in terms of young people in this town. Everything is so splintered. I was part of a group where we were looking at how we look at and address youth mental health in Kununurra and are able to support Wyndham. The number of people sitting around the table—we had all the different organisations sitting around the table that are funded to do it. There are about 10 different organisations, I think—if we look at juvenile justice and different health services—that do small sections of a little bit of the care that that person needs. It's so confusing for me sitting around the table after all my experience. You can imagine what it's like for parents and for kids.

So we're trying to look at other models in Australia with youth centres, where people come to one place and deliver their service, so young people just have to go to one place. We tried to look at that model for Kununurra, but of course it all comes down to funding and being able to have a building and support the ongoing costs of being able to deliver those sorts of services. Often there are issues with funding for lots of these programs. We've got a good art therapy one going at the moment, but it's 12 months funding. That's the other issue that I hear from people: it was there last year and is not there this year. So parents get confused, kids get confused and people just give up.

Senator O'NEILL: So the community education—'Here is a safe place for you to bring this problem and, whatever the nature of the problem is, we'll be able to wrap the care around that'—simply doesn't exist?

Dr Trust : No.

Senator O'NEILL: You have to have agency to go and find your solutions in multiple places?

Dr Trust : Yes. You can imagine being the mum at home, because this is the other complaint.

Senator O'NEILL: You'd be tearing your hair out.

Dr Trust : You've got a car that pulls up and leaves. Another one comes and talks. So you just get exhausted with support which is just not support. That's the absolute obstacle.

Senator O'NEILL: That's exactly what we heard when I was here a couple of years ago with Senator Nova Peris, just over at the country club. People came in and they just said: 'Our kids have just given up going to anything, because they were exhausted from doing this program on this day, this program on this day and this program on this day. Everybody wants to deliver it where they want to deliver it, but no-one wants to give our kids what they really need, because that's a more complex conversation and everybody's been funded to deliver and not to actually deliver outcomes for the people.' So that continues to be the situation.

Dr Trust : Absolutely, and I haven't seen that changed in 30 years.

Senator O'NEILL: So the solution is to wrap the care around the person.

Dr Trust : Yes. It's not rocket science, is it?

CHAIR: Even if it takes a while to get a physical centre, you could do that in the short term via a case manager or something like that who pieces all the bits together. Would that help?

Senator O'NEILL: Or do you need a place?

Dr Trust : I think you'll find that there are case managers already.

Senator O'NEILL: So case managers already exist?

Dr Trust : In some organisations they do, yes.

Senator O'NEILL: But they've got to manage cases outside their organisation to multiple other agencies, and that's where it all breaks down, because everybody wants to do it on their own timetable, especially if they've got a FIFO workforce coming in and out.

Dr Trust : That's exactly right.

Senator O'NEILL: If you have something in situ, you're going to have to deal with the problem of how to staff it.

Dr Trust : That's right.

Senator O'NEILL: How do we get people to come to town and stay in town? That goes back to how we skill up the local people. Clearly you're a good example of somebody who got skilled up from the local area and stayed. What's the interaction between health professionals who come and go and the quality of schooling, the quality of health services and the quality and experiences of jobs for their partners? Is that a structural problem here as well or not?

Dr Trust : I think workforce is a huge issue for lots of organisations, which is why you get a high turnover of staff in some of these different organisations. Absolutely I think staff coming into the area need to have some good, solid cultural safety awareness training on the ground from local organisations on the ground. But you also need to do that ongoing training. It's got to be relevant to their job.

Senator O'NEILL: So there's no sort of sheep dip where you get it done once and off you go.

Dr Trust : No, it doesn't work.

Senator O'NEILL: That's what's happening, isn't it?

Dr Trust : Yes, and it doesn't work. I have to do that every day with my registrars. I have GP registrars that are at the practice. They come to me as junior doctors, often from other cities. They have no experience, so we have to teach them about that, and then I have to walk alongside them every day. I've had one who had to cut a kid down from a tree after going home after dinner one night. Those sorts of things are not fixed by dipping in and, that's it, you tick the box. It doesn't work like that. You need some really good clinical supervision for staff that work in this area. I'm not sure if Simon talked about that, but that's something I think psychologists do very well. But, if you go outside of that field, certainly—

Senator O'NEILL: So GPs and nurses all need debriefing.

Dr Trust : That's right. I see stressed teachers. I see stressed police officers. I see stressed DCP workers. I see stressed community members. There's a high level of stress around some of the work that people coming into those fields have to do, especially if you work in those frontline services.

Senator O'NEILL: Could you have a general kind of decompression service that would be suitable across a range of professions, or does it have to be profession specific?

Dr Trust : No, I think you could have something. In fact, it probably would work better to have it across—

Senator O'NEILL: A general decompression?

Dr Trust : Yes.

Senator O'NEILL: And people could perhaps see that other agencies are dealing with similar problems to them as well, if they encounter one another.

Dr Trust : That's right.

CHAIR: This will have to be the last one.

Senator O'NEILL: There's so much to ask!

CHAIR: And I know you're on a timeline too, aren't you?

Dr Trust : Yes.

Senator O'NEILL: Regarding the youth suicide level, I struggle to understand what's going on when we have so many young people attempting suicide. We've heard about endemic levels of grief and loss and the use of drugs and alcohol as self-medication. We've heard about ice coming into these communities more and more. What solutions can you offer? What do we need to work towards in terms of the prevention of youth suicide and youth suicide ideation and this heady and really frightening mix of things that seems to be pressing on young people?

Dr Trust : It's such a big question, isn't it.

Senator O'NEILL: An easy one for the last question!

Dr Trust : There's no doubt that there have been many documents and many studies looking at it. We've heard coroner's inquiries and all sorts of things in the Kimberley around suicides. Definitely, transgenerational trauma, grief and loss come into it, absolutely. Family breakdown, drug and alcohol issues, cultural breakdown are all contributing to those. The reason why we're still where we are 30 years after I started working here as a junior health worker is that they are complex questions, and to have some complex, long-term solutions we need people working together on these issues, because they're not going to be solved quickly. But I'd like to think—which is the reason why I'm back here, working still—that there are solutions, and we just have to keep finding new things and trying them to see how we can slowly get things improving. There's no one organisation that's going to solve it, and there's no one solution that's going to solve it. But we do need to work together on solving it. You've got to look at all those things that are contributing to see how we can then start addressing and supporting families, for example. How do we improve and support cultural programs, language programs and all those sorts of things that help kids feel good about being Aboriginal in the first place, and—

Senator O'NEILL: So huge cultural stuff is at the heart of this.

Dr Trust : I think that's an important place to start. Then, of course, we have to look at the other things that contribute. Alcohol and drugs contribute. Family violence contributes. So these kids need to feel like they want to go home every day. They need to feel safe at home and they need to be supported in going to school and in all those things that they want to do in terms of becoming a young, functional adult.

Senator O'NEILL: What about when parents can't do that, when there has been family breakdown and you've got a relatively young mum on her own with a significant number of children?

How do you support that when it's completely dysfunctional and not upset the whole family relationship? This seems to be a very sticky point. Kids need to be safe. They need to be supported. Mum's vulnerable.

Dr Trust : Again, we really have to be wrapping support around these young families as well. I think everyone agrees that, if we can get mum and dad to be able to be good, solid, functional parents, that's going to be the best thing for all their children. The last thing you want to do is take them away and put them in another family.

Senator O'NEILL: Exactly.

Dr Trust : I understand. I've seen where you have to make that decision because kids are so—

Senator O'NEILL: At risk.

Dr Trust : At risk or already seriously injured. You have to do that. But I also see the consequence. I see lots of foster parents who struggle with being foster parents and with trying to keep kids connected to their Aboriginal families. I see kids who struggle with being Aboriginal at the age of five when they're in foster parent care. I see that at the clinic I work at. So I think we have to try. It's got to be that we try to keep the family unit together and, if families have lost their children into care, support these families to try to get their children back into their care and become functional families.

Senator O'NEILL: Do we need drug and alcohol services in the community here?

Dr Trust : We have them in Wyndham. There's Ngnowar Aerwah in Wyndham. We do have drug and alcohol support workers in Kununurra. Many years ago we had a program and a community out of town. But we don't have an alcohol facility or a rehab facility in Kununurra anymore.

Senator O'NEILL: Do you need it?

CHAIR: There's just the sobering-up centre, isn't there?

Dr Trust : Yes, there's a sobering-up shelter, but there's no ongoing program.

Senator O'NEILL: Do you need it?

Dr Trust : The short answer is yes.

Senator O'NEILL: Thank you.

CHAIR: Thank you very much for your time. If you have any further thoughts, please contact us and send them through. That would be very much appreciated.

Dr Trust : Okay.