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Community Affairs References Committee
10/07/2018
Accessibility and quality of mental health services in rural and remote Australia

KELLY, Dr Martin, Senior Medical Officer, Nganampa Health Council

NEWMAN, Mr Nicholas William, Mental Health Coordinator, Ngaanyatjarra Health Service

NIPPER, Miss Theresa, Member and Project Worker, Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women's Council

SINGER, Mr John, Executive Director, Nganampa Health Council

SMITH, Ms Margaret, Director, Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women's Council

WILLIAMSON, Miss Christine, Manager, Youth Program, Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women's Council

[14:56]

CHAIR: Welcome. I'll double-check that you've all been given information on parliamentary privilege and the protection of witnesses and evidence. It would have been emailed. Good. Thank you all for coming. It's very much appreciated. I'd like to invite you, whoever wants to, to make an opening statement and then we'll ask heaps of questions.

Mr Singer : I'll kick off. I just want to introduce with five points. The first point is that significant mental health problems and those that require antipsychotic medication are more common in our population than in the broader population. The second point is that we think such populations require visiting psychiatry services for both children and adults on a regular basis. We have had difficulty obtaining these reliably for children. Different jurisdictions need to sort out the funding support required. The third point is that in South Australia we have a failure of police to support medical and nursing staff in administration of medication to patients under community treatment orders. We're currently in a situation where we will not instruct staff to comply with these orders if there is a threat to safety of any sort. Patients on long-term antipsychotics seem to be best managed by dedicated mental health nurses who act in a case manager role. This approach needs long-term funding support. The last point is the lack of inpatient mental health resources in a location such as Alice Springs provides problems in the care of such patients.

CHAIR: Dr Kelly, did you want to add anything.

Dr Kelly : I wouldn't mind. Senators, I've worked as a doctor on the Anangu Pitjantjatjara lands for 18 years full time. I've seen a lot of changes: some for the better; some still problematic. So I've got 18 years of experience thinking about this, and I can tell you that one of the major problems we have with health care on the lands is mental health, mental illness and problems related to people's mental health and wellbeing. These are problems that are common in rural contexts, I know, but I think in remote Indigenous communities the problems of poverty, malnutrition, chronic stress, exposure to violence when very young—all of these damage vulnerable minds and brains.

The stresses are an ongoing thing. The high cortisol levels not only change how your body works and ages more quickly from a cardiovascular point of view but also the way the brain develops. In addition, there's the problem of chronic illnesses that often are a problem. Now of course there are other things: cultural differences and language barriers, where a lot of the staff are non-Indigenous, add to the complexity of mental health problems where talking is a big part of where you do your work. That said, I think it's reasonable to say that Nganampa Health Council has a very effective and robust model for delivering mental health care to adult patients on the APY Lands, and I'd recommend that kind of a model to be widespread throughout rural and remote Australia.

I'd be happy to talk more about that idea, but I want to elaborate on a couple of the points that John's already made. Is mental health more of a problem in rural and remote Australia? Obviously, it is. Our incidence of people having treatment for psychotic illness—which we do really well, I think; better than in a metropolitan setting in fact on average—is at least twice as common on the APY Lands as it is through the rest of Australia. I don't think we do depression, anxiety, chronic PTSD and the problems that are sequelae from domestic violence—that's a very unfinished journey; there's a lot of work to be done in that regard even in a system where we think we're doing reasonably well.

The point about visiting psychiatrists, I think, is worth restating. We have adult visiting psychiatrists and we have two dedicated mental health RNs who travel between our eight communities. I think that's what we need to have. We haven't had as much luck getting this for children, and I think that's a real disadvantage. Given that children grow up to be adults, it'd be better if they didn't grow up to be troubled adults. We know, for example, with schizophrenia, that treatment early reduces morbidity and increases the chance that your first episode of psychotic illness will be your last if it's treated properly as opposed to not being treated and going on to chronic schizophrenia just as an example.

I want to say a bit more about the failure of South Australia Police to support community treatment orders as well. The reason we have instruction to our staff that they're not to endanger their life or limb when providing health care to people is that we've had one nurse murdered—a good friend of mine. We've had many people, including me, assaulted by mental health patients, and we get far more threats and threats of violence than are acceptable. We have a legal mechanism for those patients who, initially, early in their illness don't want to have treatment for their mental illness but who often go on to be well treated, perfectly functioning adults if they get appropriate treatment for a long enough period of time. Yet we can't get the police to support our staff giving chronic medication once a fortnight, or once a month, when it's needed. Often that's not necessary, mind you, but for the difficult cases—the people who are most likely to be dangerous to themselves or others—the police just won't help. So we have a situation where we've got a treatment that works, we've got a law in South Australia—the community treatment orders made by SACAT—which actually supports that treatment, yet too often in the most difficult patients we have the problem of the police refusing to help.

Regarding case management, let me say this. We case manage our adult psychiatric patients or patients with mental health problems of various kinds pretty well I think. Case management is particularly important for young men and young women. What it means, in practical terms, is that we have young people who are able to manage their own lives and to avail themselves of the opportunities in life that you and I possibly take for granted. It makes their families and their communities safe. Case management means that we can provide health services, and can continue to provide health services, of a broad kind safely in our communities. Finally, it means that young people have less contact with the criminal justice system, and that can't be overstated. We want fewer young Indigenous people in jails, not more. If you want me to discuss that connection in a bit more detail, I'm happy to.

I just want to say one thing about mental health in—

Senator O'NEILL: Can I stop you there and ask about mental health, in particular with regard to young people in jail? Senator Dodson said we had to go to the jails. We've been to Derby. Today we stopped at Barkly Work Camp to see what's going on there. At Barkly it didn't look like there was a significant presentation of people with mental illness. It looks like, for you to be able to go there, it's a prerequisite that you're in pretty good shape.

Dr Kelly : That should be the way it is, by the way.

Senator O'NEILL: Exactly. But when we were in Derby, my personal impression—I'm not going to speak for anybody else—was that that could've been a fantastic treatment facility for many people with mental illness, but it's a jail.

CHAIR: Could you think about that, and I promise we'll come back to it. I'd like to get the other opening statements done before we—

Dr Kelly : Yes. I just wanted to say something about children, and I'm very happy to talk more about that. There's no treatment facility for children in Alice Springs. Remember that children rarely need emergency psychiatric admissions, but when they do they should be available. Yet child psychiatrists in South Australia have been telling me for 10 years that there is no satisfactory inpatient facility for Indigenous children anywhere in South Australia. My response to that is to say: why not? And, since we've been saying it for 10 years, why the hell not?

CHAIR: Thank you. I promise we'll come back to you on justice issues.

Senator O'NEILL: Yes, I forgot that we hadn't even done the opening statements.

Mr Newman : I think John and Martin have pretty much summed up the same sort of situation we have in Ngaanyatjarra, particularly with children: mental health.

CHAIR: Who's kicking off for NPY?

Ms Williamson : I'm going to talk first, and then the ladies would like to share some of the work that they're doing at the moment. I might build on what Dr Kelly was saying. NPY Women's Council have been operational for 38 years, and the youth program has been operational for almost 20. So we've seen over a very long period of time what works and what doesn't work, I suppose. We provide a case management service for young people, but one of the things that doesn't work at the moment is that there isn't some kind of generic support available to people. You need to have either a drug and alcohol problem or you need to have a problem where you're caught up in the criminal justice system or in child protection or at the really pointy end of the mental health service to get some kind of help. It's pretty rare that you can get just generic support on the ground. Having said that, I'm pretty sure that all the services that are sitting here now could testify that we all fill those gaps for people.

Where there isn't a mental health service or where there isn't adequate child protection support or where there isn't proper support for people to access, services like ours will step in and fill that gap. That's because we've all been around for a long time, in terms of the service, and have a reputation on the lands and people trust us. For instance, when they come to NPY Women's Council it won't be a, 'No we can't help you,' it will be a 'We might not be able to do that for you but we'll find someone who can,' or we will sit and do the speaking with people.

Part of what I wanted to say in the opening statement is that a lot of what we know about suicide and suicidal behaviour, and when young people and adults get to that pointy end, a crisis point, that is often when they'll present for support. We have an internal suicide register. Dr Boffa was talking about that. We would wholeheartedly support something like that, because we keep an internal suicide register. What that register tells us is that in around half of the situations where people have completed suicide or have attempted suicide we have a very clear link with domestic and family violence. If there isn't a clear link, there's some kind of link to being exposed to domestic violence as a child, when they're growing up, and/or to a family member who's attempted suicide.

Senator O'NEILL: Sorry, could you state that again for me? I just wasn't quick enough. Your internal register—so that's just within your organisation—shows that over 50 per cent of those who attempt or complete suicide—

Miss Williamson : Yes, around 50 per cent who either complete suicide or attempt suicide have a direct link with an experience of domestic and family violence. Sometimes that can be community violence but the majority of that is domestic and family violence. Where we don't make that direct link—when I say a direct link I mean there's a domestic violence incident. Someone walks off to try to kill themselves. That's the direct link. It's happened immediately. Where there isn't that direct link, we can make some very significant links to people who've had experiences of growing up with domestic violence and family violence, and/or where people have been exposed to someone in their family who've either attempted or committed suicide.

CHAIR: In other words, in your register there's either a direct or indirect link to domestic and family violence.

Miss Williamson : Yes, and/or where people have attempted suicide or completed suicide, where people have been exposed that. They've either seen it firsthand or they know of someone in their family that that's happened to. We know that there's fairly limited support out in the NPY region. The majority of the time people have to come to Alice Springs to get that support. And even when they do come to Alice Springs that support can take quite a long time to happen. And/or if you're not from the NT, if you come in from the APY or Ngaanyatjarra lands, you have to provide an NT based address to access that support.

CHAIR: I was going to ask you about that.

Miss Williamson : So that is a problem. We also know that apart from CAMHS, the Child and Adolescent Mental Health Service, in APY Lands there isn't any specific youth support for young children and young people around mental health. A lot of the services will be around adult mental health, which are often fly in fly out, which is a problem in itself.

Senator O'NEILL: Is CAMHS fly in fly out?

Miss Williamson : No. Maybe someone else could talk more about CAMHS. My understanding of CAMHS is that there are land based workers and there are specialists who come in and out. Is that correct?

Dr Kelly : That's true. But that's the same model the adult psychiatry system work uses. The difference with the adult service is that the psychiatrists are available to support those on-lands workers in a very much more hands on and active way, and we ring in 24 hours a day. They provide a service, as opposed to CAMHS, which unfortunately is very patchy. There's a good case worker based in Ernabella, but really that's the limit of effective child psychiatric services.

CHAIR: Is that because of a lack of resources?

Miss Williamson : I'm not clear on the reason for that.

CHAIR: Okay, we can find out.

Miss Williamson : That is true. That is a really good point to pick up on, in that often it might not necessarily be because the service is working well; it's because of the particular person that's in that role. Like Dr Kelly was saying, there's a really good person in Ernabella who has been around on the lands for a very long time—

Dr Kelly : And speaks the language.

Miss Williamson : and so has very good relationships, speaks the local language, has very good connections and understands that the traditional clinical treatment model is not necessarily the thing that's going to create the most benefit when working with people. I suppose, for us, part of the other problem is the tri-state region. We don't have a particular service that I'm aware of that covers the tri-state region. You've got services in APY or NT or Ngaanyatjarra lands, but there's no cross-border—

CHAIR: None that covers it all. Can you go into the NT. I'm aware that there were problems a number of years back around dialysis service outside NT that I understand got resolved, but now you're saying for these services you have to have an NT address to gain access to services in Alice.

Miss Williamson : My understanding is that that is correct; you need to have a Northern Territory address to be able to access NT based services. So if you come in from the APY lands you need to provide some proof that you are a resident of NT to access that service. We've got a really good example: we cover Kiwirrkurra, which is across the border in WA. Health services might go to Kintore, but they won't cross the border to support Kiwirrkurra.

CHAIR: So Kiwirrkurra will have to come to—

Mr Newman : We cover them.

Miss Williamson : Yes, but someone in Kiwirrkurra will have to be evacuated to Alice Springs if there's a suicide threat or an attempt. Kiwirrkurra is in a particularly interesting situation which is not beneficial to them, in that they kind of fall between a whole heap of different regions. They're sort of right in the centre, so NT doesn't cover it in many ways, like child protection and police. Police go across from Kintore, but child protection comes from Kalgoorlie or Perth. So they're part of the Goldfields, but not, but then they're also part of the Kimberley region. So it will depend on where that particular community sits for support. I don't think that's a common issue, but for Kiwirrkurra that's an issue. It's not a common issue for lots of communities.

CHAIR: You were talking about tri-state coverage. There's no one organisation.

Miss Williamson : Tri-state is always a challenging situation for us. There are three different child protection jurisdictions, there are different mental health supports, and depending on where you are you'll get a different response. If you're in the Ngaanyatjarra lands and you attempt suicide, you'll get a very different response than you would if you're in NT or in APY lands. That's based on case studies or experiences we've had with people.

It also is very dependent on who is currently working in the clinic. If someone's working in the clinic and they know the person that you're calling them about, they will often come out and speak to the person. But if they're fill-in workers or they don't know who it is, they might feel threatened or they might just not have enough information, and they will often refer it as a police matter, but the police will refer it as a health matter. Often when people come to us for support they'll fall through that gap. That's not a tri-state issue, sorry—that's an off-the-side issue—but that is the experience that we've had. When people turn up on the youth worker's doorstep, for instance, the youth worker is then often left to deal with it because it's not a police matter or it's not a health matter. Where you've got people in the community who have good relationships with the community, that's a really different story. They will often come and support people in the community after hours—

CHAIR: Because they know them.

Miss Williamson : Because they know them, that's right. The tri-state region is particularly tricky in a whole heap of ways. One of the initiatives that works quite well is the Cross Border Justice Scheme with policing. When people who use violence cross the borders, they'll be tracked across borders because there's that initiative across the tri-state region to work together to make sure that you can't just cross the border, offend again and not be held accountable for what you did before. But that's rare. The tri-state region comes with a whole heap of different state, territory and federal legislation and policy and different responses.

CHAIR: I'll come back to tri-state, so we keep the flow of the opening statement.

Miss Williamson : The ladies want to talk about the Uti Kulintjaku program. They just wanted me to explain a little bit of what's happening, and then they're going to talk about the work. The Uti Kulintjaku project has been going for five years. It's a mental health literacy project, so it develops resources like these that we have here. They're in the local languages. They're developed by anangu for anangu, to be used to talk with people about working with people around concepts and terms of mental health and emotional feelings. The ladies will talk more about it, but this is a good example of a local initiative, a project that's been running a long time with significant support from senior women across the lands. Sadly, it has just been defunded through the primary health network, and yet it was exceeding expectations in its performance. Pretty much everyone in the mental health sector agrees that it's a very significant project.

Senator O'NEILL: Before you go on, what was the program that you specifically referred to there, and how do you spell it?

Miss Williamson : Uti Kulintjaku. The first word is spelt U-t-i and the second word is spelt K-u-l-i-n-t-j-a-k-u. The Uti Kulintjaku has a men's program and a women's program, so the women are going to talk about the women's program.

Senator O'NEILL: The other thing that would be good to get on the record is what 'anangu' means.

Miss Williamson : It's a term used for local Aboriginal people.

Senator O'NEILL: What about 'ngangkari'?

Miss Williamson : Traditional healers.

Senator O'NEILL: Great; that's what I wanted to get on the record. Thank you. So tell us about what you're doing.

Ms Smith : Through Uti Kulintjaku we teach a lot of programs with mental health. We also work together with Alice Springs Hospital, with Dr Marcus and Dr Greg, and also another doctor comes from Melbourne. We've got about 15 women from AP land in Western Australia and the NT. We've also got a men's group that we formed to talk about mental health, and also domestic violence—everything that goes on in our community and what are our big worries.

We did a book called Tjulpu and Walpa. It's about two teenagers who grow up in different worlds. Tjulpu means 'bird', so one of the kids is named Tjulpu. Walpa means 'wind' or 'whirly wind'. In the Aboriginal way, we think two worlds: the bird's world and the wind's world. The bird's world is when a mother cares for a child, brings it up in a good world; no domestic violence or anything. But Walpa grows up to be a mental kid. She ends up with lot of trauma. She's on the wrong track: family's drinking, family domestic violence; she's going the wrong way. When she grows up she turns into that world, and then she gets helped by somebody else—her grandmother or somebody talks to her. So this Walpa, she's in a lot of mental trauma. But Tjulpu, she's got good parents and she's brought up in a good way—good living, good understanding. She knows how to care for a child.

We did that book, and we also did this other book for colouring in. We did this. The mental health hospital have some, so they can sit down and draw. Because, you know, drawing is mindful thinking; it clears your head, it clears your mind up. If you're stressed, you can do this drawing and feel free afterwards. We came up with this book as a big group. Then we came up with this system. We did this so the youth mob can use it when they take young people out camping, to use some posters. There are a lot of language words about mental health, trauma, domestic violence and a good way of living.

This is a Tjulpu and Walpa poster thing in there, with all the words. We came up with this magnet. It's got all our words for mental health and trauma, and it also talks about domestic violence—everything. These posters are in our language—they're in two languages, Ngaanyatjarra and Pitjantjatjara. Also, we've got two animations on our TV, on NITV. We've got animation on that, and it speaks in our own language. We've also got Kulila! It means 'listen'. It's all about all these stories in it. We've got the Kulila! app in language, and also a little bit in English. And we've got Smiling Mind coming up. We did about five in our own language.

These things we are doing to help our people, help our young people who are going through a mental health state and going through trauma, domestic violence and stuff like that. We women are very strong. The women, as well as the men, are the leaders of the community. We are trying our best, through language, to help our own people, but this year I think our funding has stopped.

Senator O'NEILL: What was the funding source that you had?

Miss Williamson : It was through primary health network suicide prevention funding.

CHAIR: Why was that? Were you given a reason why the funding was cut?

Miss Williamson : My understanding is that the program didn't necessarily fit into suicide prevention, and that there was a very limited amount of funds available for that particular program area.

Senator O'NEILL: How long was the funding for, and how much was it?

Miss Williamson : The funding had been going for five years. My understanding is that it initially came from the Department of Health—it was federal money—and then it was localised to NT, which is often what happens with us because we're based in NT, and then it went over to the primary health network. I don't know exactly how much the funding was, but I could find out for you.

CHAIR: It would be appreciated if you could.

Senator O'NEILL: Yes, thank you.

Dr Kelly : And if I could just apologise: just because you're a doctor, doesn't mean you can't be dumb. This is a great program. Do yourself a favour, get a copy of Tjulpu and Walpa and read it. It's terrific.

Ms Smith : These works have been done by the women on the ground. The ngangkari ladies, the healers, we're all working together. We've got the men doing the same program, and they'll be coming up with a book soon. They're going to do a book about two boys maybe, because we've got these two girls.

Also, I've gone twice to the prison to talk about domestic violence and also mental health and trauma. That's through the NPY Uti Kulintjaku program. Just twice we went. The CEO and I one night were visiting the youth detention here to talk to those from the NPY regions—that's the APY Lands, Western Australia and the four NT communities near the border. Their kids may be in prison, so we'll talk to them and help them out. That's me and Andrea. That's another agenda. We're going to be going soon to visit the kids in the prison. I've been visiting the wards with two other women, talking about children to them and also domestic violence. You ask them the reason they're going in and out of jail. It's just part of life. Anangu's life is out bush, you know. We belong to our families. So we're going to be talking to the young kids soon, our kids—not the kids from Alice Springs but only the Pitjantjatjara, Ngaanyatjarra and Yankunytjatjara kids. They're the only three tribes we'll be talking to, because we can't talk to other tribes. You know, it's not in our rules.

CHAIR: Miss Nipper, do you want to add anything?

Miss Nipper : I just wanted to talk about this book that we did, on kids in two worlds. Nowadays, kids having babies are still babies themselves; they're too young. We talked about ourselves when we were growing up. The second one is about young children nowadays; they get babies, and they're still babies themselves.

Senator O'NEILL: How are you going to fund the second book? How are you going to get the money for the second book?

Ms Smith : I don't know. We'll have to look for—

Miss Williamson : They have the funds for it. I can't be sure of the source of it.

CHAIR: They have some left from the grant?

Miss Williamson : Yes.

Ms Smith : The women's part is going to be finished.

Miss Williamson : The NPY Women's Council Domestic and Family Violence Service provide funds to the Ngangkari team to run a UK men's group. That men's group is focusing on talking about domestic violence and what men can do to start understanding domestic violence more and what they can do to start addressing it in the community. My understanding of their progress so far is that they're working through a process like the ladies did around understanding trauma. understanding the cycle of violence and then starting to talk about what men need to do in the community.

Senator O'NEILL: And coming up with their own language to talk about that and to raise awareness?

Miss Williamson : Yes.

Ms Smith : It's all in language.

Senator O'NEILL: Did you get paid for the work that you do?

Ms Smith : We get paid.

Miss Williamson : Yes. The really good thing about these resources is that we've got really clear examples of where they're used and where they're used to better engagement with people. The Domestic and Family Violence Service use it to speak with women, like with the Tjulpu and Walpa book and the cards, and the feelings cards as well. The youth program use it when we're out working in our Kulintja Palyaringkuntjaku project, where we're out talking with young people about drugs and alcohol and just basic good mental health and sexual health education. So we use these resources. My understanding is that a lot of these resources are available in the clinics, and people are using them.

Dr Kelly : Absolutely.

Miss Williamson : Dr Kelly could probably talk to that a bit more, but people are using them. The Kulila! app, as well, is free to download from iTunes. It's a free app, and you can download it, so you can put in an English word and get the Pitjantjatjara translation, and vice versa. These are really important resources because it provides a word for things that people are feeling that they might otherwise struggle to articulate. So that's been really helpful in a lot of ways, not just within NPY.

Senator O'NEILL: Therapeutically.

Miss Williamson : Yes.

CHAIR: So when we're talking about lack of access to mental health services and supports, we need to make sure that we're including these sorts of resources and funding for these sorts of resources, because I've seen not the same resources but talking to mobs over in Queensland they've got a map and some cards, and they use that to help share experiences and learnings. We need to make sure that we note that we've got to include these sorts of culturally sensitive and appropriate resources, as well.

Dr Kelly : You have to accept the fact that when you're talking about people for whom stories are critical, supporting the transmission of stories is essential. That book doesn't just help people to understand their world and what the problems they're facing are. It actually has ways forward. Our women's health people have copies of that book so that people can read it while they're waiting and also discuss the issues. Men have trouble putting their feelings into words everywhere, but when your doctor or your nurse doesn't speak your language it's just nice to have a few little things that help bridge that kind of a gap.

Miss Williamson : One of the examples that I got from the UK team before I came here was that the UK resources they used to induct new nurses in Nganampa Health—the Tjulpu and Walpa resources in particular—are used to work with women about the differences for young people growing up in an environment where there's a lot of violence and what that does to young people as they grow and what it does if their environment is different. People are using this stuff in their direct work with people all the time, which is fantastic.

CHAIR: If these resources aren't being produced anymore, because there's no funding, that has a direct result on the ability for services to be adequately provided and on the effectiveness of those services that are there. Is that a correct understanding?

Miss Williamson : Hopefully we'll be able to sell those resources, but they won't be free to people. We'll have to sell them to cover costs. I think the ladies can speak to this more than I can, but part of the benefit of developing those resources was the actual process that the ladies were involved in. Margaret said to me as we were coming in that a big part of the support that's available to her is to sit down with those other women and talk about what's going on in their community and talk about what they can do to contribute to that getting better. There isn't a lot of support unless you're a youth or unless you're disabled or unless you've got something particular going on. There's no support for the people who are doing well and maybe supporting their families to stay together. One of the great things about UK—Margaret was talking about the Tjanpi Desert Weavers program—is that they provide opportunities for women to come together and sit and be with each other and focus on something creative and something different. Margaret, you might want to talk more about that. It's not just the end product but the process people go through to get there. The ladies have developed a good understanding of trauma, and can use that to oversee some of the problems that are going on. Do you ladies want to talk about it?

Ms Smith : We did a Tjanpi weaving this morning with the CLC because it is NAIDOC week, so this morning we did a workshop. Tjanpi is our enterprise for NPY Women's Council. Tjanpi means 'grass', in our word. There were about 35 CLC ladies, maybe 20 just rocked up. They all work there. The first thing I said to them tjanpi—I was telling them a story. We sat together, started to do basket weaving and our minds were stress free. I was just telling them how I and the other women feel. We talk about the issues, the problems and what worries us in the group. That's how anangu woman talks to two or three ladies in the community. As a Tjanpi group we talk about that.

Other ladies who are on renal dialysis talk about that. They are far from home and they're very sad inside. They're living in town. That's a big issue and worry also on the NPY. We worry about all that—people come from our land into town and live on other people's land to do renal dialysis. I said that there should be renal dialysis in every community in our land—just one chair or two chairs. It wouldn't hurt the government to put that in.

We talk about all those issues. I was telling the white CLC ladies that we talk about all that and the worries are not in our chests anymore. This renal thing is really a big worry for us. I'm living with my brother and caring for him. I'm away from my family and my grandchildren. When I see other families living here I feel sad for them too. We talk about it. It's very sad living in Alice Springs. We talk and I said: 'I'm stress free. I've no worries or problems here. You've got to talk about it in the open. You can't keep it secret all your life.' They say you become stressed and get a lot of trauma in you and you get muddled up in your life. Some women keep it secret all their life and they get very sick. We are just talking about our problems and what comes up every day.

CHAIR: Is it okay if we go back to the justice issue?

Ms Smith : Yes.

CHAIR: It's something that we're very keen to hear about as well.

Dr Kelly : I was talking this over with one of our visiting psychiatrists last night. This person visits the lands four times a year for a week each time and is available 24 hours a day to take phone calls from the doctors on the APY lands.

Senator O'NEILL: That's a psychiatrist?

Dr Kelly : Yes, a psychiatrist. I was talking to them about this very problem. A number of their chronic beds in the lock-up—it has a more acceptable term than 'lock-up'—ward in their services are often filled by people who have forensic problems and who would be more appropriately managed in prison. There are limited resources and that reduces the resources for those people with mental health problems who need more than just a few days or a week or so in a mental health kind of hospital. So that's one part of this.

More importantly, sometimes we have difficulty deciding whether it is a person acting out badly who should face the consequences of that or whether it is a person who has a mental health problem. That person may have an undiagnosed condition and should be on medication but isn't or that person may be in remission and we've been reducing their medication and they are now starting to relapse, which certainly happens from time to time. Sometimes it's hard to decide whether it's one thing or another. If it's hard for us, I think it's not surprising that police officers, people on the street and people in prison sometimes have difficulty making the distinction between whether it's a person just being bad or it's a person who has a health problem that needs to be treated. I think that's a problem in prisons and I think also part of the problem is that people sometimes end up in prison when what they really need is medicine and support. That's one of my concerns about deficiencies of mental healthcare resources services in rural and remote areas. We think it's more of a problem with kids because, as I said, we've got the psychotic illness patients pretty well sorted and well serviced. Because we now have medication that has better side-effect profiles than when I was a boy—and our depots can be given it every two weeks or once a month or once every three months in some cases; and because we actually have psychiatrists that visit and support our staff—us, me and other staff; and because we have mental health workers—two of them only, unfortunately, because they have to cover an area that's 80 per cent the size of Tasmania—but because they're around we think our adult mental health patients get pretty good care. I think that's a really important thing for not only the individuals but also keeping their family and our communities safe.

If I could just tell you one story: when I first went to the lands that wasn't the circumstance. There weren't good mental health services. We didn't have psychiatrists visit, and so most people were reluctant to talk to health professionals about their relatives with mental health problems. Often what happened was that there would be these terrible, often dangerous, experiences of people being wrestled to the ground—metaphorically, if not actually physically as it was sometimes; often with visiting police who didn't know anybody, jackbooting their way into the situation. Then people were flown off to Alice Springs, and they may or may not get good care and they might or might not come back better. These days that never happens, and people requiring admission to hospital is rare. So, one of the consequences of people's experiences being positive and attempts like NPY's to improve health literacy in the communities—which is everybody's business as far as I'm concerned; it's certainly clinic business too—is that now you have people come up and say, 'Look, my son or my mother or my husband needs the needle.' That's the way it's often expressed. They're actually saying, 'This is a person who's got a problem.' They recognise that it's a mental health problem, and they know that we can help.

Unlike, Dr Boffa, I don't have a lot of figures about this. I just know that I've lived there for 20 years and there is no comparison between two decades ago the way people with mental health problems were treated and what their outcomes were and today. Unfortunately, we have to every two years justify to the federal government why we need funding for two mental health nurses, and I think we should be asking the government to justify why they're not funding. This is medicine that makes a difference. It makes not just the people who are being treated well better. We model respect for individuals and a better life, that we make our communities safer. That's really important, because we don't want children to be brought up with the disruption, the chaos and the violence in the households with people with mental illness that used to be commonplace on the APY Lands 20 years ago.

Children need a better future than that. We talk sometimes about health hardware being more important than health care, and I think that's true—running water, housing, vaccinations are all important—but we have to pay attention to health software as well, which is the minds and brains of children. I actually have been there long enough to see some of the people who were little babies and children now having their own children. They don't need to have their life made harder when it's tough enough already by having inadequate support for their teenage years from mental health services. In your assessment, how many are mental health nurses—and you're specifically focusing, in your comments, on mental health nurses to help children or cross the border.

Dr Kelly : Sorry, we're not doing child mental health as well as we should. With our adult mental health services we have, for example, 43 people between our communities on chronic depot antipsychotic medication. They get regular medication and they get regular follow up on a weekly, fortnightly or monthly basis depending on their needs. That should be the standard, I reckon, for the whole country.

CHAIR: Is that not your experience?

Mr Newman : No. I'm the only mental health nurse on the Ngaanyatjarra lands, so I cover nine communities. It's just me and 42 clients, severe.

CHAIR: So there are no female—

Mr Newman : No.

CHAIR: That's going to be an issue.

Mr Newman : WAPHA keeps knocking us back for money.

CHAIR: It just astounds me. You, at least, need a male and a female.

Mr Newman : Yes, ideally.

CHAIR: Is it because—I've got to ask—sometimes you can't find someone for that position or is it because there's no funding?

Mr Newman : There's no funding for a woman.

CHAIR: I just find that unbelievable.

Mr Newman : I know. It's getting tiresome.

CHAIR: You've got male and female?

Dr Kelly : At the moment we have two males, because that is all we could get. But we also have female health workers who are often involved, by our mental health team, in a supporting kind of role. So that gives us some flexibility. And we have nurses, often, with mental health experience, who are working in several of our clinics, who supplement that as well.

CHAIR: I'm trying to get a handle on mental health nurses right now. You're the only mental health nurse—

Mr Newman : Yes, just me.

CHAIR: covering nine communities.

Mr Newman : Nine communities, yes, from Kiwirrkurra to Warburton and everywhere in between.

Senator O'NEILL: How long have you been doing that?

Mr Newman : For four years.

Senator O'NEILL: How are you holding up?

Mr Newman : I'm getting there. It's starting to tax me a little bit. Unlike the congress, we don't have social workers or psychologists. We have a good psychiatrist who, like with Nganampa, comes out. Dr Stephen Fenner from Fiona Stanley comes out for a week every four months, and we've just secured funding to have a child psych come out too, to have a look at the kids, because we have a lot of the problems that Nganampa have as well, with kids just not meeting their milestones and with a lot of organic brain disorder stuff. It's a problem. The kids have been missed.

Senator O'NEILL: What's the cause, in your view, of the organic brain disorder and what's the scale?

Mr Newman : I think it could be down to alcohol, drugs, genes, genetics and in utero stuff. It's bizarre stuff I've never seen before within a city setting, the behaviours. A lot of it could be learnt behaviours as well, plus the beginning of mental health behaviours.

Senator O'NEILL: Could you give us an example?

Mr Newman : Yes. I don't deal with children, but my partner is the school health nurse for all the Ngaanyatjarra lands. We have a local child who can't go to school and can't go and be part of any day care setting. He's not allowed in either of these places because he's too disruptive. He's well underneath all milestones that he's met. He hasn't been followed up by paediatricians very well nor child-psych situations. Mum and Dad don't want anything to do with them, so he now lives with his aunty and uncle, as such, who can't work with him or deal with him, because he's very problematic. It was not until we got the school nurse involved that we could get some sort of care. That was the big push behind getting child psychiatry up, that boy. But then we have other children, too, who are well delayed in milestones just being missed all along. I work from 17 up to an adult. I don't see the children. I've done a bit of child and adolescent mental health, but I stay with the adults. So now we will probably have to start looking at getting a child mental health nurse in, but I think the priority should be to get another adult psychiatrist. Then we can get a child psych out—I think we are—or a neuropsych to do—

Senator O'NEILL: Is it too complex a place for a nurse?

Mr Newman : At first I think we need to get a child psych to get out to see the nature of the problems and then maybe get a neuropsych out there as well to check out milestones and to do a proper assessment. Then, from that point on, if we could get funding for a child mental health nurse, that would be a beauty. But, first of all, we'll just try to get the other guys in first to do the main assessment, then we can see how far out we are.

CHAIR: I think you were here for quite a bit of the time when the Central Australian Aboriginal Congress was here.

Mr Newman : Yes.

CHAIR: The way they talk about the team and the regional approach is very attractive—

Mr Newman : Very.

CHAIR: if you have the funding and the population base.

Mr Newman : It wouldn't have to be on the same scale as they were talking about.

CHAIR: Can I ask all of you: would you support that regional approach with the integrated services?

Mr Newman : Yes, if we can deconstruct it and redo it into a different setting.

CHAIR: Each community, obviously—

Mr Newman : Not each community. With our communities, Warburton is our biggest community. We could probably go to Warakurna as a base too, but, from there, everyone would have to travel like what I do. You can do up to 500 kays a day getting around

CHAIR: One of the other things that we've heard really strongly when we've been at hearings to date is that obviously there's no one solution. You can't go, 'It works here, so therefore it's going to work there.'

Mr Newman : That's right.

CHAIR: So there are some principles you can use, is there? You're all nodding your heads.

Senator O'NEILL: So the nature of the staffing model that Professor Boffa advanced here is pretty much what everybody needs everywhere? Then how you—

Mr Newman : I'd be happy with a clinical psych, a social worker and a mental health nurse. That would be great. That could be our team, with our fly-in fly-out psychiatrist, Dr Stephen Fenner. That would be ideal to start off with—ideal for the moderate to severe cases. I've got people who are schizophrenic and who are bipolar. I've got people with all sorts of different major mental health issues, but I don't get to see the 80 or 100 below that that are not fitting into my funding scale, so—

CHAIR: Or do the prevention.

Mr Newman : we're missing heaps.

Senator O'NEILL: Early intervention.

Dr Kelly : And we think that you can't possibly case manage more than 20 people, so you're already doing twice that.

Mr Newman : It's too much, yes.

Dr Kelly : Can I just say one thing I haven't said so far about visiting psychiatrists. In the Territory, there is this pressure—which is about money, I'm sure, and not coming from the psychiatrists—to start doing telehealth kinds of things, which sounds terrific and high IT and all that sort of stuff. Anangu are very minty and clever at using technology—young people in particular, it's true—but the reality is I think we get a huge amount of value and value adding from having a psychiatrist come in. We have a number of different psychiatrists. For example, Marcus has been coming to our communities—the same couple of communities—for 15 years. He's well-known by people. He knows people and their relationships and their relatives in other parts of the Territory. There is absolutely no substitute for them coming out because they not only do the face-to-face stuff but also educate our staff. They actually make people feel more relaxed and comfortable about mental health problems in general. It's hard to estimate how much value adding they do when they're there. We have a number of good psychiatrists who we work with, all of whom do telehealth assessments sometimes either in an emergency or as a supplement, but only a fool would think that you could abolish that visiting system and actually substitute a telehealth alternative completely.

Mr Newman : I agree.

Senator O'NEILL: We heard evidence yesterday about the preferred option for a particular person of telehealth because of the vulnerability of the services and the churn of the provision of service at Katherine. That was an option that they really said was working for them. So I suppose in these days it's about the mixed model, depending on where the person is.

Dr Kelly : It's also that, if you can't get a good service, you get a second-rate service and think that it's better than nothing, possibly. I don't know what Katherine is like at all, so I don't want to make a judgement call. We'd manage with what we could get, but we know what would be better.

Senator O'NEILL: That's why he went to Sydney.

Miss Williamson : One of the things that we were discussing prior to coming in here was the barriers to accessing mental health support. The ladies were saying that it's the privacy—the lack of confidentiality. If you're in a small community, everyone knows if the visiting psychiatrist is there and you're off to the clinic.

CHAIR: It's rarer.

Miss Williamson : Yes. So there's absolutely a place for those supports, absolutely without a doubt. But there has to be some kind of way in which people can access support confidentially.

The other thing that we would definitely support is our focus on healing and providing hope for people. In the NPY Women's Council Youth Program, for instance, we do a community meeting every year in every community where we have a full-time program, and we review that plan every year. Without a doubt, every single piece of feedback is consistent. People want opportunities to be with family in a loving, supportive way. They want bush trips. They want time out of the community. They want opportunities for healing. So there has to be some kind of, for want of a better term, holistic approach to having that more pointy-end support where it's needed—medication, psychiatry and review. Absolutely there's a place for that stuff. There's a place for mental health nurses and other support, where it's the medium-level to high-end sort of stuff. But there also has to be some kind of level of support for the community in general and for families to be able to have some time out with each other to sort of sit and heal together. People access help when they have a good relationship. That's the experience in our region. So you might not get someone who'll access a mental health service when the psychiatrist is there, but you'll get someone who will come to NPY or another agency where they've got a good relationship with them, even though they're not necessarily the service for it. They'll come to those people because that's where the relationship is. So there's got to be a—

Senator O'NEILL: And they'll connect from there if it's done well?

Miss Williamson : Yes, that's right. So there's got to be some opportunity for some community development or some kind of work done within the community to build those relationships and then where possible, where opportunity presents, to provide counselling individually or via groups or for the community as a whole.

Senator O'NEILL: Based on some of the things that we've seen, I'm leaving—this is our last day in the North—in the belief that there are people who are so poorly supported and so unable to access service in the communities that they want to be part of, which are in crisis, that they actually end up seeking respite in a prison or in a work camp because they've got housing that's not overcrowded, they've got food every day, and they've got no fighting and trauma around them. They go there for a rest. That being said, I very clearly heard one man in the jail say to us, 'This is no place to be.' So it's not like it's a first option call. It's a desperate option. Have I got the wrong impression? Is that what's going on?

Dr Kelly : I think so, as long as it's part of a nuanced view. That's not it for everybody, I reckon, but I think for some people it's absolutely true. I think another broader question is the question of work or at least structured, meaningful activity. Too many of our younger people don't have opportunities or hope. 'Where there is no vision, the people perish' is an old saying. That's what I'm afraid happens to lots of males in particular. Women in our communities have child raising, and that sort of stuff is an activity that families rally around and support, and it has meaning, it gives meaning, it's worthwhile and everybody knows that. I think a lot of men don't have as much of that going for them. The law you needed to be able to hunt and on which the survival of the family depended is not as helpful when you can hunt with a rifle and a Toyota, for example.

This is not my business, and it's a very simplistic kind of comment, I know. But I think, having seen a number of people in our communities who have meaningful activity, not necessarily paid employment, and sometimes doing out-of-the-box kind of stuff that gives their life meaning, it has often turned their lives around.

Senator O'NEILL: What sorts of jobs are you talking about?

Dr Kelly : Sometimes it's ceremonial work. One thing that used to be work was gathering firewood and hunting on behalf of older people in communities, but of course now we don't have fires so much; we have stoves. I think it's sometimes hard to appreciate that there can be unintended negative effects of some changes—which are good changes in general, too.

There is a team of blokes in Ernabella that collect the rubbish, not as a make-work scheme under CDEP or whatever but as their job. They're proud of it and they actually sometimes make disparaging comments about people who do nothing. I don't want to feed into negative stereotypes either. But there's a particular woman who works in one of our communities that I have something to do with who was a victim of horrific, destructive violence. She was a shell—an insecure, obsessed, depressed, neurotic character. She brings the mail over to the community now, finds things that have been lost and organises other people in the community. In a way, that's a factor of being removed from the domestic violence situation, and having something to do that she thinks makes her important.

Sometimes these things aren't paid employment. Sometimes they're things like building a shed. Again, I hate getting into stereotypes, but football teams and soccer teams can be sources of esprit de corps and a sense of belonging and value, and have made a difference to some of the young people that I've seen growing into adults in our communities—say, in Ernabella, Amata and Fregon.

Mr Singer : Also, in terms of employment, if you look across the APY Lands, out of our population of just over 3½ thousand, probably 70 per cent are under the age of 30. Of that age group, from 16 to 30, which is employment age, 30 per cent are employed. That's a huge number of young people that are unemployed. But it also shows that there's a real lack of older people within our communities to help and guide, and give advice to, younger people—to teach them all those skills about being parents, about work and all those sorts of things that parents and your elder family would have done in the past. I think that is also a real loss within their lives, and obviously they grow up with a lot of trauma from losing family, losing important people in the family. That loss really affects a lot of our families across the lands. Again, it's about having what you might call Western medicine but also balancing that out with our cultural practices.

A lot of our cultural practices help and guide young people because through that process our elders are involved and our leaders are involved. You get to a small community. Sometimes I look at our community and I'm looking at all our professors and lot of our older people who are senior law people—both women and men. They just sit in a community and there is no support for them to be engaging with the younger people in their environment out bush—not sitting around a store, not sitting in a little building in a hall or in a thing and having meetings all the time. In our community it's about how we engage and who the right people are, and sometimes that balance isn't there. There are a lot of areas like that. We'd like to see a bit more support in terms of not looking at our culture as a bad thing—bad things come out of it which are sometimes highlighted in media and all those sort of things, but there are a lot of good practices there that our young people miss out on. They could help them a lot in terms of supporting what that Western medicine does as well.

I think also we've had big issues in the last 20 years with the introduction of marijuana. Marijuana is rife throughout our country and through other remote areas. Nganampa Health Council and NPY Women's Council have done a lot of work. We shut down Mintabie, a mining spot, in the south of the APY lands, and that was a real hub for marijuana going out all through that Central Desert, particularly the southern area and out west. We're slowing that down because when we saw that introduction we saw a lot of psychotic behaviour introduced that wasn't there before that drug came into our communities. So that's been a lot of work. Sometimes it's out of our hands; as a health service we can't go running around arresting drug dealers. But we notice it; we've seen that change within young adolescents and young adults in terms of their behaviour.

I think on the other side as well, NPY Women's Council have just highlighted some of the work they are doing. Nganampa Health Council has just introduced into the curriculum within the schools across the lands an educational program we've adopted from IUIH, Deadly Choices. They've got two components of that Deadly Choices program: one's around the clinical side, and one's around the educational side, and we've adopted that educational side. So now within the curriculum—that's been introduced this year—there's an eight-course program, with two courses delivered each term, that highlights whole different areas. I'm happy to provide that information for your group as well.

CHAIR: Yes please.

Senator O'NEILL: That would be great.

CHAIR: I'm going to have to wind this up in a second.

Mr Singer : One other thing I think that we'd be happy to provide: through our clinics our staff keep a record of attempted suicides and of suicides as well. We're quite happy to provide that information to this committee as well.

CHAIR: That would be very much appreciated. Thank you.

Senator O'NEILL: Thanks, Mr Singer.

CHAIR: We've run out of time—in fact, we've run over time. Thank you very much for all of your time today. It's very much appreciated and very generous of you to spend the time with us. I think there's some follow-up. Mr Singer, you've just said you'd provide some more information, and I think there were a couple of others. The secretariat will be in contact with you about getting that information. It looks like you've provided us very kindly with an example of the resources.

Miss Williamson : We only brought one copy of each, but we're happy to provide everyone with a copy.

CHAIR: No, it's more important that you keep those. We'll make sure that we access those and share them. Thank you very much.

Senator O'NEILL: We do a bit of community stuff ourselves!

CHAIR: Thank you very much.