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

EDWARDS, Mr Malcolm, Councillor and President, Shire of Halls Creek

DECKERT, Mr Steven, Acting Chief Executive Officer, Shire of Halls Creek

HAY, Mr Jake, Regional Program Manager Youth, Shire of Halls Creek

[16:37]

CHAIR: I welcome our next witnesses, from the Shire of Halls Creek. Can I double-check before we start that you've all been given information on parliamentary privilege and the protection of witnesses and evidence?

Councillor Edwards : Correct.

Mr Hay : Yes.

Mr Deckert : Yes.

CHAIR: I know, Councillor Edwards, you've done this a number of times. Thank you for coming. We very much appreciate it. I invite whoever wants to to make an opening statement—if all three of you want to, that's fine—and then we'll ask you some questions.

Mr Hay : Certainly. I've prepared a few points in line with the terms of reference for the committee. As a bit of an introduction, I've worked within the shire for the last six years in various youth worker capacities. I've worked as a front-line youth worker and I've managed youth programs. I've worked in Halls Creek. I've worked in Mullan community, Billiluna community and Ringer Soak community, all of which fall within the shire boundaries. It's 144,000 square kilometres, or the size of Greece, so there's a lot of ground that needs to be covered as a youth worker.

I currently manage the Olabud Doogethu program, which is Kriol, meaning 'all of us together'. Essentially, we're a referral based youth service for young people that are disengaged.

Historically, we've worked with those young people that are engaged with the criminal justice system. We accept referrals from the police, youth justice and child protective services to work with these young people in a case management based program. We look at the reasons why these young people are offending, the reasons why they're disengaged and at risk in the community, and we try to provide pro-social activities so that those instances of reoffending are reduced.

Our team in Halls Creek comprises of me and two case development officers. Each of us has been here since the inception of the program, which is six years, so we have quite a significant amount of experience between the three of us. We also manage six Aboriginal casuals around the remote communities within the shire. They provide generalist youth activities to young people within the communities of Mulan, Billiluna and Ringer Soak.

Adolescent mental health has been something that we have been very heavily focused on over the years, and it's something we've definitely advocated for in any forum that we have been invited to. I've compiled a series of points based on our professional experience over the years in Halls Creek, and in the surrounding communities, and what we've noticed in the realm of mental health service delivery for young people.

I will start with term of reference (a) which is:

… the nature and underlying causes of rural and remote Australians accessing mental health services at a much lower rate …

I have a few points on this. Service delivery for adolescent mental health favours a drop-in model. Professionals travel from Kununurra to Halls Creek every fortnight to three weeks to visit their referred clientele. This is often shared with Warmun. Rapport building with clientele is difficult, and intensive therapeutical intervention is almost impossible. Multidisciplinary meetings with a focus on youth at risk, for example the Halls Creek YARN—Youth at Risk Network—meeting, are flawed and are not improving outcomes for young people. YARN meetings are often rescheduled. Different staff are sent to represent an organisation rather than a consistent representative. Meetings have a sanctioning focus rather than a rehabilitative focus.

Young people are not always aware of the services that exist. Mental health is not a primary focus of health promotion initiatives in the region for young people; therefore, the youth have little understanding of what can be done to assist them. Responsiveness of mental health services has a direct correlation to the ineffectiveness of the current service delivery model.

Confidentiality is also a major issue, with agencies expecting information sharing without the adequate consents. In small towns the perception of everybody knowing your business can prevent a young person from wanting to engage. Stigma around mental illness and a reluctance to discuss it plays a significant part in why people in our remote communities will not access the service. People are more visible in a remote town, and confidentiality may be less assured.

Term of reference (b) is:

… the higher rate of suicide in rural and remote Australia …

Young people present with higher numbers of neurodevelopmental disorders in the Shire of Halls Creek. A lot of the time this goes undiagnosed unless they have engaged with youth justice services, and that's for age 10 and over. These young people are more likely than their peers to have other mental disorders, such as anxiety, depression and antisocial behaviour. Suicide response teams are not locally based and have little connections to Halls Creek families.

Young people in the Olabud Doogethu program consistently present with low baseline scores when tested against the Rosenberg self-esteem scale, the Oxford happiness questionnaire, the social identification scale, which relates to belongingness, and the Kessler psychological distress scale. This indicates that clients have very little to no resilience skills. Extremely low or no school attendance for high-risk clients are keeping them out of services' visibility to identify the issues early, unless they are a CPFS or youth justice services client.

Senator O'NEILL: Could you just say what those letters stand for?

Mr Hay : Sorry; my apologies. That's Child Protection and Family Support, and the other one was youth justice services. The current funded service to develop the Halls Creek suicide network is based in Queensland, with an outreach worker in Darwin.

CHAIR: Who's that?

Mr Hay : That's Wesley Mission. Services like this are not successful, and have not been able to mobilise community buy-in; however, they continue to be funded. CAMHS—Child and Adolescent Mental Health Services—have closed open cases on multiple occasions due to little or no engagement with the client. So they've had a referral, but when they come to Halls Creek every two to three weeks, they can't find the client or the client does not want to engage, making rapport building extremely difficult. Drug use plagues youth as young as eight years old; little exists in the realm of drug and alcohol counselling for those under 16.

Term of reference (c) is:

… the nature of the mental health workforce …

Legacy issues with regard to poor service delivery exist. Young people may have had a negative experience with a mental health professional due to the quick turnover of staff, their lack of presence within Halls Creek et cetera. This may prevent them from re-engaging in the future.

There is a range of complex factors that add to the delivery of mental health services in the region, and recruiting people with the right skills and experiences and then retaining them over a longer term is problematic. Staff burnout is high across all human services programs. Tertiary-qualified professionals are coming through the system and moving to regional communities to gain experience to support a career promotion back to cities. There is no intent on staying longer term—in many of the cases; not all the cases.

Little consultation occurs with our communities with regard to identifying the level of need and service design. Decisions about operating models are often focused on budget constraints rather than the number requiring access to the service. Too many decisions are being made from Perth, Broome and/or Kununurra with little engagement from Halls Creek. Child and Adolescent Mental Health Services—CAMHS—have begun hiring psychologists to support their frontline teams. This is a step in the right direction.

Term of reference (d) is:

… the challenges of delivering mental health services in the regions …

Staff turnover for child and adolescent mental health workers in Halls Creek is extremely high. Staff do not have an adequate understanding of geographical and cultural concerns for Kimberley clientele. This has resulted in the township of Halls Creek going through extended periods of time without any Child and Adolescent Mental Health Service workers. This issue is even more problematic in our remote communities, mainly for Balgo, Mulan, Billiluna and Ringer Soak. Service delivery needs to be malleable towards Aboriginal cultural concerns; staff members need to learn the right language and the right approach to sensitive to cultural practice.

The cost of doing business and delivering a service is significantly higher in the Halls Creek shire when compared with the rest of the region, such as the rest of the Kimberley and the Pilbara. This was highlighted in the state Regional Services Reform Unit's October 2017 report Resilient families, strong communities: mapping service expenditure and outcomes in the Pilbara and the Kimberley.

Term of reference (e) is:

… attitudes towards mental health services …

There is not enough focus on trauma-informed psychological and therapeutic services for our young people. The service model has become a tick and flick process. Clinical settings are not conductive to mental health treatment for our Aboriginal communities. We need to develop less formal, non-clinical settings that incorporate families to address the social context of issues, such as neglect, and build on protective factors.

Term of reference (f) is:

… opportunities that technology presents for improved service delivery …

Exploring the opportunity to develop a telephone based health service or a telephone based psychiatry service would improve access to mental health speciality care that is often not available in remote communities. Services such as Olabud Doogethu—ourselves—could case manage this service as part of the overall care for young people. Although telepsychiatry has the disadvantage of the patient and the psychiatrist not being in the same room, it can enhance feelings of safety, security and privacy for many patients ffering this as a professional development service to place based solutions addressing the issues would improve our capacity to upskill our Aboriginal workforce.

Term of reference (g) is any other related matters. In the financial year 2016-17 the shire intervention program working with youth at risk in the township of Halls Creek had two young people sent to Banksia Hill Juvenile Detention Centre for criminal activities. One had a pre-existing acquired brain injury and the other had a diagnosed organic brain injury. Sanctioning young people with pre-existing brain injuries also presenting with mental health issues should not be a solution to the problem. Place based solutions keeping young people connected to family and country are needed. New solutions that have an integrated approach, such as community justice centres, have to be explored. That concludes my opening statement.

CHAIR: Thank you very much.

Senator O'NEILL: It's a pretty good one.

CHAIR: That was extraordinarily helpful. Thank you. Senator Pratt, do you want to kick off?

Senator PRATT: You said that there are issues of drug use in children and that there are no services available. What are you currently doing to support those children? What should be available? There aren't really any specialist services around. I'm not aware of any in a metropolitan area, let alone here. If you were to see something accessible here what would that look like?

Mr Hay : It's a unique challenge because we have youth presenting with drug issues from such a young age. In our service, Olabud, it's often about linking them to the right information sources. A couple of nights a week we do boys and girls nights—we call them yarn nights—at the youth centre. We tackle the tough issues for young people. The young people prepare the dinner and we sit at a dinner table discussing these issues informally. Often we'll invite other service providers, such as the drug and alcohol team, to come in and provide information on those issues. They're learning about the dangers of drugs and alcohol and they're also being empowered with skills to reduce their exposure to and usage of those adverse elements.

Also for us it's a matter of doing some intelligent case management with those young people and linking them to pro-social activities that might make them not want to engage in those antisocial activities, such as linking these young people with sport and physical activities such as hiking, getting back to country and engaging in cultural activities. It might be going to the gym. For some of the older ones in the youth demographic it's about a sense of purpose and getting them involved in meaningful employment that is not work for the dole. These sorts of pathways often have follow-on effects that result in a reduction or an elimination of the use of drugs and alcohol.

In a perfect world I would like to see some sort of intensive one-on-one mentoring or counselling for those young people. I referred in my notes to the fact that this is a small town where everyone knows everyone's business, so it has to be confidential and people need to be mindful of that. It would give those young people strategies to stay away from those negative influences of drugs and alcohol. I think our young people would be quite responsive to that if they were supported by youth workers that they know, such as us.

Senator PRATT: You also mentioned that there were significant levels of anxiety and depression in children and young people. We know that there are both social determinants and genetic and biological determinants of that. How would you characterise the social determinants of the anxiety and depression in Halls Creek and surrounding areas? We've had other evidence that talked about high levels of poverty, overcrowded housing and cultural disconnectedness, as well as the strength that comes from culture. What are the key issues driving that? What are the key things that make people resilient?

Mr Hay : You've almost answered it in your question. A lot of the issues that cause these young people to feel feelings of anxiety and depression do come from their home environments. Services can only work the hours they've got to work in the day. There are no services that exist in the overnight period, and this is a time where a lot of these traumatic episodes happen for young people, such as not knowing who's going to be there when they go home—their house might be overcrowded, there might be family coming in from all sorts of places and suddenly you've got 20 people in a three-bedroom home. You might also have issues such as excessive noise and excessive alcohol consumption which scare a lot of the young people away from their homes at night. If you were to drive down the streets of Halls Creek past 11 o'clock, you'll see a significant youth presence all night.

Senator PRATT: So that kind of means that many of the children don't have a regular routine at home?

Mr Hay : That's correct. Life for them is survival. Seeing what they see, in instances where there's constant partying, chaos and disorganisation, they do build a natural strength and resilience that comes with a lot of lower socio-economic communities. There is a perception in the Halls Creek community that the young people are out at night because they're bored or they're seeking adverse behaviours to participate in, such as committing crimes. If you ask the young people, most of them can't go home for reasons due to safety. Safety is a big concern.

CHAIR: I rushed to let Senator Pratt ask questions, and I didn't check with either of our other witnesses whether they wanted to make any opening comments.

Mr Deckert : I'll just say a couple of words. This is a learning experience for me as well, because this is day six in Halls Creek for me. I'm here more to support Jake and hear what he's got to say. I've only known Jake for six days. He's very passionate and he knows what he's talking about. That's why the shire was happy to support Jake to speak on behalf of it. While I've only been here six days, I've had 14 years experience in Laverton. The issues there are similar to here. On a lot of what Jake has said, without me knowing all the detail, I can certainly understand where he's coming from and I know what he's talking about.

Laverton is probably not quite as well off as Halls Creek. Laverton doesn't have the services that Halls Creek has—I've noticed that there seem to be more people here able to deal with all the issues around Halls Creek. On the services that are coming from outside Halls Creek, I can see with travel time and the way that the services work, because of the way it worked at Laverton, that, when they're on the ground in Laverton, they don't have a base or an office. It's a matter of them going around the community trying to find who they're looking for and, a lot of the time, they're not there or they're not available. It's a challenge for those visiting services. Even getting some office space in town and a regular meeting place would be advantageous.

As I said, I'm here to learn and listen, and I appreciate the opportunity for the shire to say a few words. Generally the shires are the first place the community come to when things aren't going well. We tend to be the people they come to, to solve all the problems of the world and that sort of thing. We might be able to help with the federal budget, I don't know. But, in the short time I've been here, I haven't had anything come across my desk in relation to health services. Generally people appreciate what's there. This is probably a discrete area where we could do with some more assistance.

CHAIR: Councillor Edwards, did you want to add anything?

Councillor Edwards : I've come here for the same thing: to support Jake. I think he's presented very well. He's had a lot of experience in that youth area. He's a valuable person from our shire. We do have another councillor, Councillor Loessl, who is a registered nurse, but unfortunately he had to go to Ringer Soak this morning. It's a pity he is not here to also present.

Senator O'NEILL: We might be able to hear from him on a telephone hook-up at a later point in time.

CHAIR: Or he might want to put in a submission; that would be really appreciated too.

Councillor Edwards : Okay, I will tell him that.

Senator O'NEILL: My first question is: where did you come from and why did you stay? We need to replicate the passion that you have and the insight that you have in multiple communities. The retention of people with the skill sets that you have and the cultural understanding that you appear to have just doesn't seem to exist.

Mr Hay : I'm from inner-city Sydney originally.

Senator O'NEILL: And just wanted to get out?

Mr Hay : No, I really like Sydney. I did youth work in the Redfern community, which is probably our Aboriginal hotspot in inner-city Sydney. I was working with a lot of homeless youth there, a lot of youth that had mental health concerns as well. I also worked with people that were coming out of detention. It was my job to reintroduce them into being functioning members of society. I came up here not knowing too much about the outback or the Kimberley—thinking I knew a little bit, but you sort of throw the old university degree out the door when you arrive in a place that is so different to what they are teaching at university. I started as the youth worker for Mulan community, which has a population of 130 people. It's down the Tanami Highway four hours from Halls Creek. It's still part of our shire, but it's quite a small community.

Senator O'NEILL: Was that a full-time position in that community?

Mr Hay : That's correct, so living and working in that community.

Senator O'NEILL: How critical is that to the capacity to actually do the work that needs to be done in mental health?

Mr Hay : It's paramount. It's very important. The problem is retaining staff that can live in that remote circumstance. There is one shop in Mulan; it's open six hours a day. Prices are very expensive. Besides that there's nothing to do except shopping.

Senator O'NEILL: How did you survive it?

Mr Hay : I read a lot of books; I kept fit; I went hiking. I guess a love of nature has allowed me to stay in the Kimberley as long as I have. I'm also on my own. I'm single; I don't have any dependants. I'm an Army reservist and we have a NORFORCE unit here, so that keeps me very involved with the community. To speak on behalf of my team, who are also my age and have come from similar city circumstances, they've also found a love—I guess it's a blank canvas. Lack of opportunity also presents the opportunity to try new things. We're very lucky as a team of young community service workers—we get to try things that we might think will work. Sometimes they do; sometimes they don't. From that we've built a very good professional rapport, and that's probably the main thing that keeps us here.

Senator O'NEILL: Do you think there needs to be some sort of auditing and careful vetting of people who say that they want to come and do this kind of work? 'I'll come and it'll advance my career, look good on my CV,' and then they go. We really don't need that kind of exploitation. We need to find the personality type, the skill set, that's actually going to bring an asset to the community and stay long enough. We've heard from all of our First Nations representatives about a declining sense of trust in service providers and an erosion of help-seeking because of that retelling of their stories. So what do we need to do to get the right people here and get them to stay? How does the government help with that?

Mr Hay : It's an interesting question. To preface my answer, the first thing people say when they arrive here to work is, 'How long are you here for?' They don't see Halls Creek as their home; they see Halls Creek as a transitioning point for greater things. It's remarkably difficult to find the right people. People can say the right things in the interview. A lot of interviews are done over Skype. When you do face-to-face interviews like we have in our service it costs a lot of money. We've had people come up, do the interview and say they're really excited to start when being offered the job. We had one gentleman step off the plane to start work in Kununurra and he decided it was too hot, much more hot than when he came up for his job interview, and he hopped on the plane going back. So it is extremely difficult to find the right people. Our organisation in the past, when recruiting for remote communities in particular, has implemented a series of psychometric tests just to see people's longevity and see where their passions are. I can assure you, looking back on the staff that I've had—the staff that I know have performed and the staff that haven't been able to perform at the level we expect—that those psychometric tests are quite accurate.

Senator O'NEILL: That's helpful, because that's a practical possibility as a way for us to proceed.

Mr Hay : I found that life experience also helps—people who have worked in the industry or visited this part of the country and who know what they're getting themselves into. That often helps in the recruitment phase.

Senator O'NEILL: What about the universities and their capacity to put people on placement in these sorts of contexts, support them and provide proper cultural knowledge?

Mr Hay : Yes.

Senator O'NEILL: Is that happening?

Mr Hay : It's interesting that you say that, because we've started that conversation with the universities in the last few weeks to get a couple of people up here from Curtin and UWA to do placements. Obviously we would support them in knowing what to expect and ensuring they have the appropriate initial cultural understanding of what they're getting themselves into. Our organisation is looking at that. It's something that's taken us longer than it should have, but it is definitely something that I see as a step in the right direction for the future. Historically, I haven't known too many people across the Kimberley who have done their work placements up here.

CHAIR: The other thing is that what they're finding with medicine—this does not always hold—is that students from the bush who go and study are more likely to go back to the bush.

Mr Hay : Yes, that's exactly what happens.

CHAIR: Have you had much experience with Kimberley people leaving the area to get training and come back?

Mr Hay : Not from my service, no. I am aware of it happening across other services, but it hasn't happened as far as we're concerned.

CHAIR: In youth services?

Mr Hay : Yes. We've trained our staff. We've put young people through certificate II and III in community services, with the hope that they might one day be attracted to a job such as ours. So we are thinking for the future, but not so much at the university level.

CHAIR: Thanks.

Senator O'NEILL: Thank you for the indication of the costs. We'll look at that October 2017 study. With regard to attitudes, you talked about there not being enough focus on trauma-informed care. In response to item (b), you also talked about neurodevelopment disorders, a failure to diagnose and the structural problems that that generates.

Mr Hay : Yes.

Senator O'NEILL: Could you talk about both of those a little more fully.

Mr Hay : Sure. I'll just find my point.

Senator O'NEILL: Item (b) was the neurodevelopmental stuff.

Mr Hay : Yes, I've just found it. The neurodevelopmental disorders I speak to mostly come under the realm of the fetal alcohol—

Senator O'NEILL: FASD?

Mr Hay : Yes, FASD, which I'm sure you've heard a lot about in your travels.

Senator O'NEILL: Yes.

Mr Hay : There are a lot of papers and a lot of estimates of how much has gone undiagnosed. You hear conservative estimates of 60 per cent of our young people living in these communities having undiagnosed fetal alcohol syndrome. I've seen some papers that suggest up to 90 per cent. If it is such a prevalent issue, it opens a Pandora's box for supporting those young people in their schooling and providing the right mentors and educational assistance in the school environment. It means there's a whole lot of funding that's going into a different school of thought. Our young people actually might be committing crimes or might be disengaged because of their cognitive abilities. So that's something we're trying to change our thinking around. We also advocate with others we come into contact with. We may be dealing with quite significant issues as far as that neurodevelopment goes.

Senator O'NEILL: FASD is a result primarily of alcohol overuse during the gestation period.

Mr Hay : It doesn't have to be overuse. Studies suggest that you could—

Senator O'NEILL: Minimal?

Mr Hay : Yes, you could have one session on the drink when you are pregnant, and that could cause fetal alcohol syndrome.

Senator O'NEILL: Given the scale of self-medication that we're hearing about in the generation of people who are becoming parents, is FASD on the increase or the decrease, or is the rate just being maintained?

Mr Hay : It's hard to say. I've been here for six years, and I haven't seen any change in that time. I haven't heard of any change. But I still regularly see pregnant mothers drinking alcohol. So, from what I've seen, I would say that it's maintained.

Senator O'NEILL: So the problem is not going to go away?

Mr Hay : It's not going to go away organically. It's not going away.

Senator PRATT: What is your view of what the protective factors for young people are—the things they turn to that help them in their anxiety, distress or depression? Is it culture? Is it country? What are their strengths? Is it their friendships?

Mr Hay : It's funny; it's a bit of a cliched statement that I make to my staff: it's hard for our young people to reach for the stars if they don't know what the stars look like. Their frame of reference in Halls Creek is very limited. We don't have doctors coming out of Halls Creek and we don't have lawyers. The No. 1 thing that I think really helps young people in Halls Creek with their resilience is a sense of purpose and a sense of belonging—a sense of direction. Often that sense of direction is limited to what they see on television: they want to be a football player or a policeman. Or they want to be a youth worker, because they've worked well with a youth worker. I think a sense of direction and a sense of purpose are really important. Another important protective factor for young people is safety. Safety goes hand in hand with routine—being able to go home to a safe, nurturing environment is probably one of the most important things for young people. Also having a network of either peers or people in the community you can go to—and that's also why it's important to have longevity amongst the staff who come to Halls Creek.

CHAIR: What level of interaction do you have with the mental health hub?

Mr Hay : Zero.

CHAIR: Why is that?

Mr Hay : We interact directly with child and adolescent mental health services. Their service delivery, over the years, while it's here has been good for what they're working with. Coming in from Kununurra, there have been too many periods of absences and lack of consistency. We're constantly having a new worker reach out to us and say: 'Hey, I'm new. What do you know about the Kimberley?' We're happy to facilitate their interactions with the young people and get them to meet, and I don't want to take away from what is good and what is happening, but there are a lot of initiatives that don't get off the ground. It's often a matter of working with what we've traditionally worked with, and it's them reaching out to us, or us reaching out to them when we know it's going to be a successful program. We don't want to send our young people to things we're not investing in ourselves. Does that make sense?

CHAIR: Yes, it does. Thank you very much. With every single witness we've had, all day, I've just wanted to keep talking. Thank you very much. We very much appreciate the effort that you have put into identifying those issues for us.

Senator O'NEILL: I'm going to ask some questions on notice about what you see as the solutions that would work with the problems that you describe. In particular, if you could come up with your view about youth suicide—particularly with suicide prevention and suicide ideation, given the nature of the young people we are talking about. So those are questions on notice for you.

Mr Hay : Thank you.

CHAIR: The secretariat will be in contact with you about that.

Mr Hay : We appreciate you coming to Halls Creek.