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Education and Employment References Committee
25/09/2018
Mental health conditions experienced by first responders, emergency service workers and volunteers

HARVEY, Professor Samuel, Chief Psychiatrist, Black Dog Institute

[14:10]

ACTING CHAIR: I now welcome representatives from the Black Dog Institute. I understand that information on parliamentary privilege and the protection of witnesses and evidence has been provided to you. I invite you to make an opening statement, and then we will ask you some questions.

Prof. Harvey : I've brought along copies of some of the research studies and documents which I mentioned in my written submission and which I'll mention in my opening statement by way of formally tabling them.

ACTING CHAIR: Are we all happy to accept these?   

Senator URQUHART: Yes.

Prof. Harvey : I want to start by thanking you for inviting me to come and talk to you on behalf of the Black Dog Institute. My training is as a psychiatrist, so I've certainly dealt with many first responders suffering from PTSD, and previously I've run clinics, within the London Ambulance Service and here in Sydney, that have seen first responders. But more specifically I'm here to talk about the research program that I've been running at the Black Dog Institute around first responders.

The Black Dog Institute, as you may well know, is a global leader in mental health research and one of only two independent medical research institutes in Australia focusing on mental health. Since 2012 we've been partnering with the University of New South Wales to host Australia's largest research program focused on first responder mental health. Over that six years we've partnered with a number of first responder organisations, primarily but not solely in New South Wales, and produced a range of research outputs that have resulted in: the creation of new mental health training within a number of first responder agencies; the world's first expert guidelines about how PTSD should be treated when it develops amongst first responders; and Australia's first mental health and wellbeing strategy for first responder organisations, which was launched in the NSW parliament.

One of the key messages I was hoping to come here and convey today was around the importance of good quality research and the help it can provide in guiding your committee and others trying to balance how to deal with mental health problems amongst first responders. I'm aware that you guys have heard a lot of submissions from individuals and organisations, and those individual opinions are of course an incredibly important part of the story. I suppose I also wanted to make note of the fact that history gives us a warning about the risk of ignoring some of the research evidence when we think about how to respond to this problem, and I make mention in our submission of psychological debriefing. I apologise if someone's already spoken to you about the history of psychological debriefing, but, in brief, psychological debriefing became very popular in first responder agencies in the 1980s and 1990s. By the late 1990s there had begun to be concern amongst some academics and clinicians that it may not be helpful, but by that stage it was almost ubiquitous amongst first responder agencies around the world. By the time we did randomised control trials that looked at it and were able to bring all those together in 1998, in a landmark systematic review, what had become clear was that debriefing wasn't helpful and that there was some research evidence that suggested that, rather than preventing PTSD, first responders who got debriefing were actually at increased risk of PTSD. So really it's a salient lesson, I think, about how rolling out things that seem like a good idea and are well intentioned can have unintended consequences.

At the Black Dog we've tried to take those historical lessons, and, in this program of research we've been developing around first responders in partnership with the first responder agencies, we've said quite clearly that intervention should only be rolled out once as an evidence base. Part of what we have shown over the last six years is that you can do well-conducted, well-controlled trials of interventions so that you know what works and what doesn't work.

I think we can reasonably say that New South Wales is now being seen by the rest of the world as a leader around developing evidence based interventions for first responders. I'll give one example of that. We've conducted a number of studies defining the importance of managers and leaders within first responders in terms of setting the culture, as you mentioned earlier, but also in responding when people become unwell. In that pack, I've included a number of the papers we've published in journals that highlight the key role of managers. The problem we had was that no-one was clear about whether you could train managers to do that role better and, if so, what that should look like. We partnered with Fire and Rescue NSW to develop a new four-hour training program for their managers, where, based on those research studies that we had in there, we really focused on giving managers the confidence to have those discussions earlier, because that seemed to be one of the key things that was holding them back from doing that.

Importantly, given what I said before, we put that through a randomised control trial. We randomised all of the duty commanders in New South Wales to either get the manager training or not get it. We followed them up for six months. What we found was that the managers who had got that training had significantly increased levels of confidence after six months, that their behaviour had changed and, perhaps most importantly, when we looked at the impact of that on the firefighters that they were managing—and the measure we had from them was their sickness absence records—that there was a substantial reduction in sickness absence amongst the teams with managers who had got that training. That helped to make the economic argument about how there was a 10-to-one return on investment for that type of manager training. We published that paper in The Lancet Psychiatry, which is one of the top psychiatry journals—there's a copy of that in your pack as well.

The point of that is to show that you can do that type of trial within a currently working first responder organisation. We now know that that type of manager training works. It's now part of the ongoing manager training in fire and rescue. We've been working together with the ambulance service of New South Wales and with Ambulance Victoria to develop an online version of that same manager training so that it can be rolled out more broadly.

Manager and leadership training is only one part of the solution. One of the things that I'm challenged with, as a researcher and a clinician in the area, is for us to be able to give sensible advice to first responder organisations on how they can take what we know from the research evidence and put that into practice. That's why we've developed some evidence based frameworks around what an employer should be doing to create a mentally healthy workplace, and then tailored those specifically for first responder organisations in that mental health and wellbeing strategy document for New South Wales first responder organisations. We've got a copy of that in the pack as well.

The other thing I want to highlight is that we know what best practice clinical treatment looks like for people with PTSD. As a clinician, I've seen numerous first responders who, even after they have put their hand up and asked for help, don't get good quality evidence based treatment. That is incredibly frustrating. As part of efforts to try and avoid that situation, we've produced guidelines for clinicians, managing first responders with PTSD, where we've laid out what good evidence based treatment looks like—there's a copy of those in your packs. I also note that there have been a couple of studies since the production of those guidelines that talk specifically about some new treatment programs for first responders that are being run here in New South Wales. I've included one of the key papers that has come out in recent months regarding particular types of psychological interventions for first responders with PTSD.

In conclusion, I want to thank you for inviting me here to speak. I also want to acknowledge that the work that Black Dog has been able to do in New South Wales has been as a result of funding from the New South Wales government, particularly the ministry for mental health, and from the icare foundation in New South Wales. I want to acknowledge the agencies we've worked with here in New South Wales. Fire and Rescue, New South Wales Ambulance, the New South Wales Police Force and the Rural Fire Service have been amazing partners in our research. I think that to do research in this area you have to be able to partner with the organisations.

The other thing I would note is that this is a difficult area to get research funding for. We got some funding from the government to sort of kickstart this or to fund the core of this research program, but we have gone to a number of the standard research-funding bodies, like the NHMRC, with proposals to look at some of the unanswered questions, because there are key unanswered questions still in the field. We really don't have much of an idea about the symptom trajectories of individual first responders. Without understanding that, we just don't know the answers to those key questions: 'Should we be doing regular screening of first responders and their mental health? If we do that, how do we follow that up with interventions that will prevent people progressing?' We don't know enough about retiring first responders and what that process of retirement means for their mental health. Those are research questions that we could absolutely answer with funding, but it's very difficult to get funding for a group like first responders through those standard research schemes, because one of the responses you get is: 'Well, this is a very focused research question on a very focused group of workers. Is that really the role for a general scheme?' So I suppose I would conclude by raising the prospect of whether your committee may be able to think about ways in which we can try to get some targeted research funding to answer some of those unanswered questions that I've tried to summarise in our submission.

ACTING CHAIR: Thank you, Professor Harvey. I'll just kick off with a couple of questions. We've heard today, in particular, two different views of the organisations that you have been partnering with. We've had some quite negative views from lived experience as to what's been described as a negative culture within those organisations, the same organisations that you've just described as world leaders in this area. So do you believe from your interactions with these organisations that there has been a cultural shift and that they have actually acknowledged that this is a very real issue and are trying to take the learnings that you are providing them on board?

Prof. Harvey : Yes, I would say there has been a cultural shift over the last decade within these organisations, and my interactions with senior people within each of the organisations in New South Wales suggests that they're very involved in and very committed to trying to work out what they can do to improve the mental health of first responders. But then, at the lower levels within any organisation, there is a spread of responses. One of the papers that we provided there, which was looking at ambulance services, shows there's a spread of manager expertise and confidence around mental health and attitudes to mental health, and that has a real impact on employee mental health. So I think that at the upper level these organisations are aware of the issue and are proactively trying to do stuff. As I think the manager training that I described indicates, it's sometimes at the lower levels of management within an organisation that you've got to get things right, because they're the people that an individual will come face to face with if they put their hand up to help or if they're showing signs, and they're the people that you have to train to respond properly. That's an ongoing process.

ACTING CHAIR: As a follow-up, from the research you've done so far, is there good clinical evidence as to the balance of treatment versus prevention? Are there any preventative techniques that can be embedded in the training process in people's university education or their induction into these organisations? Is there preventative resilience training that is effective at mitigating any negative outcomes in the long term?

Prof. Harvey : I think that's a key question and a big question. We know that within psychiatry we are now getting much better at prevention. Ten or 15 years ago, the idea of trying to prevent somebody developing a mental disorder was really only in its infancy, and we've made huge strides over the last decade. When I think about resiliency training and prevention within first responders, there are three factors to consider. The first is: is there stuff that you can do in terms of the selection of individuals into those first responder agencies to try and select individuals less likely to become unwell? The evidence to date is that you can't—none of the pre-employment selection processes that are used has a very strong evidence base. I apologise that that paper is not in your pack, but we have done a systematic review, published last year, that brought together all the international literature around pre-employment screening for first responders. A single sentence summary of that is that there is not much good evidence out there.

We can define a group of individuals who are statistically more likely to become unwell over a period of time. But the problem is that none of those measures is very specific. So you will end up denying a large number of individuals the chance of having a career in first responder work to potentially avoid one person becoming unwell. At some point, there is going to have to be a decision made about how many people we are happy to deny a career to to prevent one person from becoming unwell. At the moment, we don't even have a number around which to make that decision. From my point of view, there is not really any good-quality evidence around pre-employment screening at the moment. But there are studies going on to try and better that.

There are two things that can happen after somebody has become employed. The first thing is that you can try to help that individual become more resilient. We have just finished a study here in New South Wales involving firefighters working at rescue stations—another randomised control trial—where we tested out a new way of trying to enhance their resilience by teaching them mindfulness skills that they were able to practice on iPads. The results from that are quite promising. I think the continuation of that work is that we will be able to develop individual resilience training programs. The current situation is that there are a lot of people offering resilience training programs that don't have an evidence base. That is why we are putting this one through this trial. I think what we do know is that, for individual resilience programs to work, you have to be teaching people cognitive, behavioural or mindfulness skills and it has to be an ongoing process; one-off training does nothing. That is why we have been using online training, a feasible way to be able to keep these individuals practising these skills.

The second thing you can do after someone is employed is think about what you can do to make the organisation more resilient for them. I don't think we should put all of the responsibility around prevention on the individuals; actually, the systems they operate in is a huge part of what defines their level of resilience. I think manager training is a huge part of prevention in terms of getting the managers to respond appropriately. There are those other factors you talked about around organisational climate—having an organisation where it is relatively normal for people to ask for help, get help and return to work. Those are the types of things that, at an organisational level, promote resilience.

We know a little bit more about what works with that than at the individual level but there is still ongoing work around both of them.

ACTING CHAIR: Once someone is diagnosed with PTSD, in terms of treatment and getting them back into the workforce if possible, how advanced are we in terms of our knowledge about the best approach? What is the clinically most efficacious way of treating people once they have reached the point where they are diagnosed with PTSD?

Prof. Harvey : We know a lot more about PTSD now. PTSD, as a diagnosis, only became formally recognised in 1980. Over the 38 years since then we have learnt an enormous amount. We now have psychological and pharmacological treatments that we know work. The problem is that they need to be modified for first responders. I think, a lot of times, first responders end up not getting those types of evidence based treatment. They end up getting, for example, supportive counselling rather than trauma focused therapy. There are a range of reasons for that. But in terms of your question—'Do we know what works?'—the answer is absolutely yes. I think what has been difficult is getting that type of treatment to the individuals in a timely manner. Often, by the time someone like me sees them, it is much harder to get a good response because they have been unwell for many years.

Senator PATRICK: There is some news in there for us who have been travelling the country listening to first responders talking about this. I will use the experience in Adelaide, where we have ambulance officers going from one job to the next, or going from a job to ramping to the next job. Their belief is that a big part of the cause of the problem is about not being able to stop and deal with the last incident. I do not know whether you differentiate that—between stopping and pausing—when you say debriefing doesn't work.

Prof. Harvey : I would differentiate that—and thanks for the opportunity to clarify that. When I talk about debriefing, I am talking about a critical incident debriefing process. That would typically involve an outsider coming in and all of the individuals involved in an incident having to talk about and ventilate their emotions and their experience. Typically, that would happen the following day. In saying debriefing doesn't work, that doesn't mean appropriate management after a critical incident doesn't work. What we do know is that having individuals feeling supported by their organisation and their manager after a critical incident is very predictive of people not becoming unwell. What a lot of organisations internationally and here in Australia have started to look at is having a peer led response to an incident. I don't know whether any of the organisations you have been hearing evidence from have talked about their peer support programs, where you have groups of first responders trained to be able to monitor people after an incident. That type of stuff is seen as best practice in responding to it.

The issue you mention in particular—whether people should be taken off further jobs after a critical incident—is one of those key questions we just don't have an answer for. If you look at rates of PTSD in the military after people came back from Iraq and Afghanistan, there was a thing called operational tempo. That was about where you had soldiers being sent back on future deployments without the normal break that they get between deployments. They were at increased risk of PTSD. So there has been some suggestion that in a first responder service an ambulance officer being sent out to another incident straight after having attended an obviously unpleasant and traumatic incident could be seen as the equivalent. But we don't have particular research evidence to know whether that is the case.

Senator PATRICK: I am an ex-submariner. It may be a stressful and interesting job, but I wouldn't claim to have seen the sorts of things that an ambulance officer sees that we have talked about today—ice, suicides, car accidents and those sorts of things—on a regular basis. Notwithstanding troops who may be involved in a firefight, not even Army people would see that sort of thing. It is a different sort of trauma, I would imagine.

Prof. Harvey : It is a different sort of trauma. One of the reasons we often look at the evidence from the military is that we are still struggling to build up evidence around first responders whereas the military has had more dedicated research funding. So, often, we find ourselves trying to take lessons from the military for this group for that reason. But I take your point: what first responders have is many years of cumulative trauma exposure. And we know that that is a really strong predictor of who develops PTSD—their level of cumulative trauma exposure across their career.

Senator PATRICK: The military can waste $1 billion and no-one seems to care. Yet we have the New South Wales government or the South Australian government really struggling to provide services to people. This is a federal inquiry that could potentially bring people together. We've got all of these different emergency services across the country almost looking at this thing disparately. There's no joint effort. I'm guessing you would say that, if you looked at it in its totality, you would amortise the cost across all of those services and we could get a good outcome if we made a recommendation that you approached it nationally rather than on a state basis or even, perhaps worse off, on an individual police-ambulance-firey approach?

Prof. Harvey : I agree. Of course whatever intervention is proven to work needs to be tailored for the individual organisation to make sure it fits within the other things they're doing. But, actually, the key research questions that each organisation are facing across the different states is very, very similar. With economy of scale, if we had a funded program of research looking across the states and agencies, you could actually get traction to answer some of these key questions.

Senator PATRICK: And you don't see that at the moment, do you?

Prof. Harvey : No. There is a network of researchers working in different states, but, to date, it's been very hard for us to collaborate on some of these things because of a lack of research funding there. But we're well placed in Australia. We've got a number of international experts around PTSD and organisational psychiatry. We should be well placed to get answers to these; we just need some help.

Senator URQUHART: It's very refreshing to hear from an academic who actually has done the research. You talked about the training that you've provided to Fire and Rescue NSW at that middle-management level. I think you said there was a 10-to-one return on investment for training, which is fantastic.

Prof. Harvey : Yes.

Senator URQUHART: I've always had in my mind that it's better off to spend the money there and reap the rewards somewhere else than have broken people and try to fix them up down there, so that's good. My question is in relation to that manager training. I think you said the evidence was there that it has improved—the relationship between the middle manager and the people who are working within that group. You talked about firefighters and ambos. Have you done any work with police on that level of management training?

Prof. Harvey : No. I have a number of other research projects ongoing with the police in New South Wales, but that hasn't involved manager training up to now.

Senator URQUHART: Can I ask why? Is that linked to funding? What is the rationale for the police? The reason I'm asking is we've heard evidence not only throughout the course of today but also in other inquiries in other states and from the police people—although they're not coming today and neither are the ambos; I'm going to say that again: the ambos and the police from New South Wales are not coming today, which I'm really concerned about—about how the top chiefs of the organisations are really on board. I think you said that earlier in an answer to a question from the chair. But it doesn't seem to trickle down, and that really concerns me. We've heard quite damning evidence around the culture of the NSW Police Force, that middle level of not caring about what they're doing and the fact they think people should toughen up. I just wonder: what's the rationale for that training not being taken up by the NSW Police Force? Do you know? If you don't know, it's fine.

Prof. Harvey : I don't know. I can make a few observations though. I have regular meetings with the NSW Police Force. In fact, in New South Wales there are a number of meetings which allow the different organisations to get together and to share what's happening, and so I've certainly had an opportunity to present those results to representatives of the NSW Police Force. As I say, the NSW Police Force have been a willing partner in some of the research I've done. I think the honest answer is: I haven't gone to them and suggested doing that particular program with them because it was something that we already had partner organisations doing—that the particular research questions that we're answering with NSW Police Force are those that fitted in well with the programs they were already planning.

Senator URQUHART: That's really useful that you have the groups come together and share stuff. One of the questions I would ask is: what national leadership role do you think that the Commonwealth government could actually play in promoting the model that you're talking about in terms of that training or other helpful procedures?

Because we have these different jurisdictions that all seem to do things differently. They have lots of peak bodies that talk a lot but never seem to share information and don't—and I don't know whether value is the right word—seem to value if someone's doing it really well. Maybe that's a good opportunity for us—do you see a role for the Commonwealth government within that?

Prof. Harvey : I think that it can be difficult to keep abreast of the things that are happening in other states and the initiatives that they're trialling there, and so I think some mechanism to make that easier would be very beneficial. That's not to say that New South Wales needs to preach to the other states because I think there are some things that we could really learn from that are happening in other states as well. One of the things that happened in New South Wales was that the Mental Health Commission here started chairing regular meetings which led to us producing that strategy document. The good thing about that meeting was that it brought together the appropriately senior people from each of those organisations to talk about this, and something equivalent at a federal level could be very useful.

I find often these meetings or these sorts of conversations need some sort of glue and shared purpose to stick them together beyond the overall one. One of the things that has helped with the conversations in New South Wales is that we've had a bit of research funding to say: 'Well, these are research projects we're going to do. Let's discuss exactly what the questions are and how to test them.' If there was a similar thing happening at a federal level, then that would be very powerful.

Senator URQUHART: If the three organisations got together across the Commonwealth—fire, police ambos and other first responders—and said, 'How do we stop the incidence of mental health and suicides amongst our workers?' is that not enough?

Prof. Harvey : That is enough but, inevitably, one of the things that would come out of that meeting would be: 'For some of the key questions you're asking me, should we be doing regular monitoring? How do we do prevention at an individual level?' I would end up saying to them: 'I'm not sure. These are the options we think might work, but we don't have the research funding to test them.' My experience of working with the agencies here is, if you can say to them, 'We've now got funding to develop and test this thing,' my experience is that they're only too happy to help out with that because they don't have internal funding to fund that research.

Senator URQUHART: The institute's research indicates that paramedics are at a higher risk of PTSD symptoms than other emergency service workers. Can you tell us why that is the case.

Prof. Harvey : This is not an Australian phenomenon. Internationally, if you have a look, ambulance workers seem to be at slightly higher risk than other emergency service workers. The honest answer is: no, we're not quite sure of the reason for that. I think they are different from other emergency service workers in that they come from a health professional background, which the other two don't. There's been some discussion around whether the nature of their work involves more regular exposure to trauma than some of the other agencies who undoubtedly do get exposed regularly but perhaps not with the same frequency. But the honest answer I can give is: we're not sure.

Senator URQUHART: When do you expect your final research into pre-screening to become available?

Prof. Harvey : We would expect that to be available by the end of this year. We're at the point of working together with the organisation to check that we all agree on the interpretation of those results, and we'll be looking to make it publicly available in one of the academic journals before the end of the year.

Senator URQUHART: Is it possible that you'll do an earlier draft or summary of that and that you could share that with the committee?

Prof. Harvey : Certainly, I'd be happy to, but I would just need to check with the organisation that we were partnering with to see whether they were content with that.

Senator URQUHART: I think that would be useful for us in our deliberations and getting together reports. So, if you could, that would be really helpful.

Prof. Harvey : That would be fine.

Senator LINES: Thanks very much, Professor Harvey. It's been really interesting to hear from you this afternoon. One of the witnesses we heard from earlier was suggesting that when the police go to a job there's a checklist they go to, to ensure it's safe. Is there a way you could build in some kind of a mental health check to that, and would that be of assistance?

Prof. Harvey : It's a good point, because as a group they are very onboard with the idea of checklists, and it's a discussion we've had with firefighters here in New South Wales. When they come back from a job they are drilled in checking their equipment so it's ready for the next job. One of the programs we are currently testing with them is to try and extend that into checking themselves and to check on themselves, and to check on their mates at the end of a job, and to see whether that kind of simple raising of the profile and that education makes a difference.

Senator LINES: It obviously go towards changing a culture.

Prof. Harvey : Yes, exactly. Clearly, the reason we're doing that is we think it might help. We're in the middle of the trial, at the moment, to try and confirm that it does. But I think, definitely, there is no point going in to groups of first responders and suggesting something that just doesn't fit with the culture and the individuals. I think that type of notion of checking is a good idea. The only thing I would say is that internationally there have been some academics who have written about needing caution with the way in which you do that type of education around mental health. There is a potential risk that if you get it wrong, if you instead find yourself encouraging first responders on a daily basis to appraise whether they have been made unwell by their work yet, that in itself could cause problems. So one of the reasons we're putting this through a trial is that there are, I think, risks as well as benefits with that type of education, and you've got to get the balance right.

Senator LINES: It's interesting, because we're always told as parents and members of the community that where we think kids are suicidal we should ask.

Prof. Harvey : Yes, and I would say that the evidence around asking about suicide is clear, that asking about suicide doesn't make it more likely they're going to think about suicide.

Senator LINES: But you're not sure that same kind of asking would translate into a workplace.

Prof. Harvey : I think if you ask about symptoms of distress and feeling overwhelmed, if you ask about that in a way that may makes individuals feel that becoming unwell is an inevitable consequence of their career, that could cause problems.

Senator LINES: Except that the work frontline responders do is traumatic and stressful and, probably—if we kept statistics—it's more traumatic than it's ever been. I'm from Western Australia. The police recently have dealt with horrific domestic violence. Two teenagers, just last week, drowned. Two days before that, a family of four was found murdered. That's almost an everyday occurrence in their job. That is the job.

Prof. Harvey : That is true. I would agree with you that it's impossible to imagine having a career as a first responder without feeling distressed and upset and traumatised by what you've witnessed. But it is possible to have a career as a first responder and not develop PTSD.

Senator LINES: Yes.

Prof. Harvey : So I think what we're trying to find is the right way to get the balance of that message between—

Senator LINES: One in 10 is pretty strong.

Prof. Harvey : Yes.

Senator LINES: We heard from some witnesses, this morning, who'd been first responders. Is it worth considering looking at careers in the same way that the Army does, where you sign up for a certain period of time? One of the people who works in the firefighting area in the Act said, 'After 30 years, what do I do?' And one of the other people we heard from said that he'd had a 12- or 13-year career but six years in he realised that was probably it. So is that something people have considered as well?

Prof. Harvey : It's certainly a discussion I've heard had. One of the papers we did showed very clearly that the more trauma you're exposed to, across your career, your risk of PTSD gradually goes up. So, of course, one can make an argument that at a certain level of trauma exposure that risk becomes unacceptable. The problem is that we also have the opposite narrative of first responders often telling us that it was when they left the force that they really began to notice symptoms and problems emerging, because being a first responder was such—

Senator LINES: Because they're not operating at that level?

Prof. Harvey : Yes, and it was such a key part of them and their self-worth and their social support. If you said, 'No-one should be a first responder for more than 10 years,' then there's a risk that you are shifting the problem to a lot of people becoming unwell when they're asked to leave. In that list of big unanswered questions, one of the things is around monitoring of individuals' trauma exposure. When a radiologist works around X-rays, they have a tag on their belt that monitors how much radiation they're exposed to. Some people have asked, 'Should we be doing that with first responders? Should we know that a particular firefighter has been exposed to an awful lot over the last five years?' My sense is that, yes, we probably should, but my reluctance is that we don't quite know what is the right thing to do with those individuals when we identify them. I think that's—

Senator LINES: What you're measuring?

Prof. Harvey : Yes. That's the type of thing. We just need to be able to find a way to work out from a research point of view: what's the right way to do that; what's the right way to monitor; and what's the right thing to do when you notice people's trauma exposure creeping up? I really hope that, in the next five years, we get those answers because I think those types of things will make a big difference going forward.

Senator LINES: Senator Urquhart and I have been chatting to each other because we both worked as union officials before we were senators and we both know how adversarial the workers comp system can be, which creates problems in and of itself.

Prof. Harvey : Absolutely.

Senator LINES: Is that something you've looked at as well: how we make that process less adversarial?

Prof. Harvey : It's not something we've published any research about, but, as a clinician, I would absolutely agree that there is something about the process of workers compensation claims that can get in the way of individuals recovering. We need to do whatever we can to reduce that, while making sure that we have appropriate scrutiny around diagnosis and treatment. I agree that the process itself becomes quite damaging in many of the cases I see.

Senator LINES: Thanks very much.

ACTING CHAIR: Professor Harvey, thank you sincerely for your time today. It's been very useful for the committee.

Prof. Harvey : Thank you very much.