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

BYERS, Mrs Lynette (Lyn), Secretary, Central Australian Rural Practitioners Association

[16:22]

CHAIR: The committee will resume. I welcome Mrs Lyn Byers, from the Central Australian Rural Practitioners Association. I just need to check that you've been given information on parliamentary privilege and the protection of witnesses and evidence.

Mrs Byers : Yes.

CHAIR: I invite you to make an opening statement and then we will ask you some questions.

Mrs Byers : Thank you for inviting CARPA to present to the committee today. We really appreciate the opportunity. We're a small voluntary organisation and we are cross border. We were formed in the late 1980s by healthcare providers who saw a need to support remote health practitioners in the delivery of quality health care in unique and challenging settings. We are a really loosely structured voluntary organisation. Members join because they are passionate about remote health and they bring this passion and their expertise to the different areas of the organisation.

The sorts of things we do are about supporting education and professional development. We sponsor forums like the AMSANT leadership forum and we develop resources, such as orientation to remote primary healthcare manuals and videos, and we play a key role in the governance and production of the remote primary healthcare manuals, which is a suite of clinical guidelines for clinical practitioners working in predominantly remote Indigenous Australia. They are mandated across the whole of the Northern Territory, and they are used in South Australia and Western Australia, and we are involved in the governance of that.

I was sent by CARPA to represent them at this inquiry because I am a member. I am also a remote area nurse and midwife. I am an endorsed nurse practitioner in the speciality of remote and I am a qualified mental health nurse. I've worked in mental health in Central Australia as a clinician and member of the team but also as a manager of the remote mental health outreach team. I'm obviously passionate about quality health care in very remote settings. So my background, my passion and my context are in very remote communities.

I came a bit early to this because I wanted to hear what my colleagues were saying when I saw the program. I'm more aligned to the three presenters you saw in the previous session, and I've worked for some of them. I've worked with some of them and am aligned with what they have to say. I would certainly agree pretty well with what they all had to say. But I think we need to be really clear that there is a very big difference between very remote and rural and remote. I've lived here in Central Australia for nearly 20 years now—I came just before Martin Kelly—and I don't see Alice Springs as remote, because that's my context and what I'm used to. So I don't call this remote, whereas if you come from Sydney all the way out here, especially if you drive, you might say yes. The very remote I'm talking about is well out of Alice Springs. At the moment I'm based at Yuendumu, and I don't see that as terribly remote. It's three hours drive west-north-west on a bitumen road, and it's got internet cover, so that's very good.

CHAIR: So it must be all right!

Mrs Byers : It is compared to most the communities I've worked in. That's just so you've got the context for the sort of population and the needs that I'm talking about.

I don't know if you want to ask questions or whether I could just talk. I have some dot points here that we wanted to talk about related to your terms of reference. There are a lot of things that we've heard today that we endorse, and also the submissions that have been put in by the National Rural Health Alliance and by CRANAplus, particularly CRANAplus, because that's the only organisation representing very remote Australia across the whole of Australia. They've already said a lot of stuff about the facts and figures and details, but I would be looking at them and at some of the stuff the previous presenters said—particularly Christine from NPY and Martin and the gentleman from Ngaanyatjarra Health Service.

When you look at very remote communities, you have to look at Maslow's hierarchy of needs. Down at the very bottom, you need something to eat, you need somewhere to sleep and you need to be able to keep warm, before you worry about counselling or addressing your health issues. That's what's missing in most of our very remote communities, particularly in the Northern Territory here. If you don't get enough food or if you're homeless, that's your priority before you worry about your mental health disorder. If you're in that situation already and you're not safe because of domestic violence or whatever, you have to manage those before you can manage your mental health. That is where I think the really big gap is. If we don't manage that stuff well then it's a bit late to get the mental health nurses in to do preventative work or to get the psychiatrist to treat what has happened.

CHAIR: The social determinants.

Mrs Byers : Yes, the social determinants stuff. But we have to have strategies. I think a very fundamental strategy is helping people to sort out their Centrelink. Centrelink is a really difficult thing to sort out. I've sat in Centrelink offices for four hours trying to help people work that out. You get someone for whom English is not their first language and who doesn't really understand mainstream processes, and they haven't got a hope. I do know that at the moment we have actually got more people living off one income because their Centrelink's been cut off, and they're all trying to buy food in very expensive stores to survive. So I think social workers or the relevant people to help sort out Centrelink are a huge gap.

CHAIR: If I had a buck for every time I've heard that recently, I could probably fund some of these services.

Mrs Byers : Exactly. You've got to sort your money so you can buy blankets or food. You might not be able to buy healthy food or whatever. I've got a perfect example of that in the community I worked at. Someone went on holidays for six weeks and came back. Everyone said: 'Oh, he's relapsed. He's bad. He's attacking the shop. He's doing that.' This was very unusual. I'd never had this young fellow do that before. I got him in the clinic and started talking to him a bit. He lived with his elderly grandmother. They'd both gone to Alice Springs for a little while for a holiday. He'd come back, leaving his grandmother behind. We'd managed to cobble together a thing. She got meals under the Home and Community Care program, so we'd sort of slid one in on the side for him. Because he came back but she didn't, his meals didn't come back. He'd lost six kilos in six weeks, because he was literally starving. That's why he was hassling people. He didn't need to go off and have more antipsychotic medicines or anything. He just had to get his meals sorted out. I really think that's very strong.

There were some of the underlying causes of rural and remote Australians accessing mental health that you had on your thing. There's certainly a lot of stigma and fear. In the Northern Territory in very remote communities, we still have the legacy of the stolen generations. It is still going on. If you have a mental health issue or a problem, for a lot of people there is a fear that welfare will get involved with your family and your children. That happens if you go through domestic violence too. If you are a victim of domestic violence and you get help on that but there's a mental health issue, there is a very strong fear now still alive for Aboriginal people that welfare will be involved in your family and you might lose your children. That does have an effect.

CHAIR: Does that prevent people seeking help, because if they acknowledge or let someone know they're not well their kids will get taken?

Mrs Byers : There is a possibility. Whether it's a real factor or not, it's a fear.

CHAIR: What I'm talking about is the fear.

Mrs Byers : Yes, there is definitely a fear. With the issue of the stolen generation, of the loss of children, John Boffer talked about having a lot of children in care in the Territory, whether it's proportional or not. There are a lot of people in kinship care. But having welfare involved in your family—in these very remote communities you have literally no control over your life. Your house is provided by the government. Your income comes from the government. You're under a westernised system of services and things like that. And if things aren't quite right some other service will appear and want to do something in your life. It is very hard when you may not have finished primary school, you may not be literate in English and you may not be able to find a support person to argue for you about the positive things that are happening in your life and to articulate them so that I can understand them. I come along and I might see these things and see they're all deficiencies—to understand what's a strength, what's a deficiency and what's important in one culture versus what's important in another. What I might think is important may not be nearly as important to somebody else. So you have very little power.

You've probably already heard about the intervention in the Northern Territory. At the same time the intervention happened, we had the super shires. So we basically lost a lot of control. That really affected mental health in a lot of ways. Lack of control means nobody's well. We've got that from the British studies, the public servants. The people at the bottom of the hierarchy are less well than the people higher up. So the less control you have over your life, it doesn't matter what ethnic group you're from, the less well you're going to be.

You've probably heard a lot about services. We've talked quite a bit about child and youth services. I think John Boffer talked about a model. That's Alice Springs. I must say, for a small country town in the middle of nowhere, which is what we are—we're a service town here; we don't have a lot of industry—we do have quite a few services. We have excellent services. The remote communities, outside of Alice Springs, are where you don't have them. Child and youth mental health service is different from the adult one. I've worked. I'm not a child and youth specialist but I worked a lot with the Child and Youth Mental Health Services that we have in Alice Springs when it was set up. And I had breakfast with two child psychiatrists this week. With adult psychiatry, when you've already got a diagnosed mental illness and you are managing that and you might be in remission—like you do with diabetes or something; it's well managed with medication—that's one thing. Child and youth, where you're really trying to get in before you get too bad, need long-term ongoing interaction. You can't fly into a community, spend a week there and disappear again for another four months. You're going to make very little difference, in that case.

Where you have got the strength, and this points back to something one of the other presenters said—it was Martin Kelly, about telehealth. The remote doctors used to have a clinical forum every Friday morning. They used to ask me to dial in as well. They wanted me to dial in because they wanted to ask me things. They were talking about mental health services one day. This is the remote doctors, for the Northern Territory government, who cover the remote clinics in Central Australia. They were reflecting about mental health services. They felt that with the increase in mental health services in remote community adults they were much more knowledgeable and supported and were able to manage them much better. It was very much what Martin Kelly described for the Nganampa lands. What they felt was lacking was the same sort of thing with child and youth, that they don't feel as knowledgeable and they don't really know as general doctors what to do. They were asking for that sort of support. Like Martin says, with telehealth you're not going to get that upskilling. That's what they felt had really helped to manage, in the big multidisciplinary picture, the remote adult patients that needed mental health intervention.

CHAIR: Sorry to interrupt. In terms of access to kids having access to mental health education and awareness at school, do you have any knowledge or understanding of that?

Mrs Byers : Yes. In remote communities it's basically really limited. It's down to what the school can manage. There's no way I'd be a schoolteacher in a remote community for anything. The kids are really hard work. The schoolteachers do a fantastic job. These kids don't all get to the preschools and things, which we do have in remote communities, so quite often they get to school when they're five. And it's a totally different model of care to what they've been brought up in. The cultural way that children are brought up is a collective model. It's much freer. The discipline that we understand is a lot different from the sorts of disciplinary models that I use with my grandkids, for example. So it's a different way of being brought up. Then, all of a sudden at five, you're brought to a mainstream model of schooling and you're told to comply with that, where your first language isn't necessarily spoken. If there are teacher aides there that's great, but your first language isn't even spoken.

Senator O'NEILL: You've got a recipe for disaster there, haven't you?

Mrs Byers : Yes. You are all of a sudden expected to conform to a totally different system that you may or may not have been exposed to in a totally different language and you're meant to achieve these outcomes. So I think the teachers really are doing their best concentrating on the three Rs. The model they're talking about with Nganampa and bringing in some of that stuff into their communities is fantastic. I think some schools try to do it but some don't. The Northern Territory remote schools had three educational sites to cover all of Central Australia's remote communities—so 32 plus the Barkly—and then they defunded that. So they don't even have that anymore.

It comes back to what the gentleman from Ngaanyatjarra Health was saying about all the children who are missing milestones and things like that. That's all very well, but you've lost it by the time you get there. If they are seven and they are that far behind all the rest, you've probably lost it. That's about starting right at the clinic from when they're very little and making sure they're having their routine child health checks—like my grandkids do. They go to the Flynn Drive Community Health Centre and they have routine child health checks. So having that relationship there is important, as is being recognised and teachers having any sort of capacity to recognise kids that are falling behind, rather than just trying to contain and deal with the rest. The schools need a lot more support in this area. By the time you get to see a child psychiatrist you've really missed the boat. You need to have been recognised and in other care before you do that.

We don't have, for example, some of the psychological trauma counselling. These things are just not available. We don't have a child and youth mental health service beyond Alice Springs in Central Australia. In South Australia, in the Nganampa lands that Martin was talking about, their mental health service for children and youth comes up from Adelaide. Apart from the two workers they've got based in the communities their child and youth service comes up from Adelaide. The Northern Territory itself has a child and youth mental health service based here in Alice Springs. It now has a waiting list. I was involved in it when it first started and it didn't have a waiting list, and now it has a waiting list—and it is primarily town based children, from all ethnic groups. It is not for any one ethnic or cultural group. So there's just no capacity. I know one of the psychiatrists is working with the remote doctors to help them upskill, but it depends on capacity. If you don't see people clinically and you're doing upskilling something else misses out. So there's really nothing for these children—and now that the education department is not funded for the psychologist there is nothing through that pathway either.

The other issue about mental health for very remote which often gets missed and I wonder about is the service providers and the workers—people like myself, the remote area nurses; the schoolteachers; the shopkeepers and all these service providers. Very remote communities are inherently unhealthy places to live. It doesn't matter whether you grew up there or didn't. There are basic things that you need. Food is expensive. I've got resources to get good food—I've got credit cards and the ability to transport stuff—but other people don't. So food is expensive. The water won't taste as good and you'll have to dilute it with stuff—it's bore water. The air might not be as good because of the dust and so forth. It will be difficult to find places to exercise, because of dogs and so forth. It's inherently an unhealthy place to live.

I can escape from it and go and work somewhere else, but a lot of service providers do come out here to earn money for whatever reason. They can access a crisis mental health service by coming to the clinics that are in these remote communities, but there's not a lot of stuff for their mental health and wellbeing. CRANAplus provides bush support services, which is for remote health professionals and their families. That's a fantastic service, but I'm not so sure what the schoolteachers, the shopkeepers all these other service providers have, apart from the Aboriginal people that live there. So you have to remember those population groups. It would be the same for the station owners and people who work on stations and areas like that. They often get left out. I hand out beyondblue and lifeline phone numbers—because, really, what else can I give to them?

The gentleman from the Ngaanyatjarra lands talked a bit about cognitive assessment and things like that. There is a lot of confusion and misunderstanding about where that sort of thing fits. Are we looking at mental health issues? Are we looking at organic dysfunctions or cognitive impairments—things like that? And then people get bounced between services, because there's not enough service for any of those out in remote areas, I can assure you. Then people basically just refer to everyone and everything they can think of, hoping that somebody will be able to do something for this person. So that is a different sort of area that needs to be looked at.

Senator O'NEILL: It's like pin the tail on the donkey—you just have a bit of a stab in the dark and hope that you're going to connect them up to somebody that'll see them.

Mrs Byers : If you go to children, sometimes children have difficult behaviours. In remote communities, primarily the care is led by nurses and Aboriginal health practitioners. Most communities in Central Australia do not have resident doctors. The person who's there 24/7 is most likely to be a remote area nurse, possibly an Aboriginal health practitioner. So it'll be me that you'll come to see. Someone will come and I'll be looking at this child, wondering: is that a normal behaviour or not? I'll have a visiting doctor who'll come, so if I'm a bit worried I might say, 'Can you come see the visiting doctor?' and they'll come. Now, if they've been around for a while, they might know what services are in Alice Springs. I'm more likely to know that than they are, and then they might say, 'Right, we'll refer him to the paediatrician and we'll refer him to child and youth mental health and we'll refer him to allied health, and we'll hope that somebody at some stage will see this child.' Depending on how it's written and whatever, it might be two or three years later. In the meantime, the family has to deal with it. I've been around for a while; I use services like NPY. They aren't going to be clinical, but they will actually make sure that that child and that family are being supported so that there's food around for it and a bit of help here and a bit of help there. But, especially for children, it's often too late, down the track. But the bouncing of services is really about resourcing and capacity and where things have been allocated.

Senator O'NEILL: You've heard about the No Wrong Door basic model that the Congress were talking about. Is that the solution? Do you need to be more closely plugged in, in some way, to a service like that, where you can say to somebody, 'I can't understand what's going on here, despite the best that I've read and thought.' How could you get somebody to Alice to go into that No Wrong Door and get at least a resolution and then do the work back home?

Mrs Byers : Congress talked about that, and they do a great job here and all that sort of stuff. It's really that most the services are pretty full already. There's not the capacity. I could ask the doctor to refer to multiple services, but people will go on a waiting list. So you'll get in. The paediatrician might be happy to see them, child and youth mental health might be happy to see them, allied health might be happy to see them, but it might be two years later, because you're on a waiting list if you're remote.

CHAIR: And the damage has been done.

Mrs Byers : Yes, especially for children.

Senator O'NEILL: Even at Congress.

Mrs Byers : Congress are a self-contained service, so they're employing their own. There are 32 services in Central Australia. There are only six, I think, or maybe eight that are Aboriginal owned and run and are self-contained services. All the others are supported by the government. So they'll be referred to a government service. If I refer someone to Congress, that will depend on whether we can get money to get them to town, whether they've got accommodation when they get to town and whether an appointment comes up, because Congress's service is already full with their own clientele before they'll take someone from remote.

Senator O'NEILL: That's what I was trying to get to. If there was that Congress model somewhere closer, the costs of travel would be part of it but they would be reduced, because it would be closer, and there would be a bucket of primary healthcare money. If, instead of having to go to service A, B, C, D and E—and we've talked about alcohol and other drugs and mental health all being in together—there was a bucket of money for children, could that start to solve the sort of problem you've been describing?

Mrs Byers : Possibly. Certainly, remote clinics run by the government are virtually the hub. So, if you come out as a mental health clinician or as the alcohol or other drug clinician or as the paediatrician or whatever, you'll be flying in and out, because the populations in Central Australia are too small. We're vastly different to the Top End. Our communities range from a size of about 80 up to about 850. You've got 32 discrete communities with populations that small, so you've got economies of scale. You work out of the clinic, and they would be fly-in fly-out from hubs like Alice Springs, which is virtually the model now. I think there's something in the terms of reference about the staffing, so I've got some points about that. But that's really what you do. But for child and youth you need to be much more consistently on the ground. Then you've got to have the infrastructure in place.

We talk about things like overcrowding in remote communities, but if we go to build a new suburb in Melbourne or somewhere the first thing that happens in that new suburb is that the developer goes in and puts in roads, sewerage and electricity. If you want to build a new house in a remote community you have to sometimes extend the power house and put in a new generator, so there's enough power to actually run three more houses, and you have to check that the bores will sustain more houses and things like that. I know at Yuendumu we're on water restrictions virtually. There isn't enough water there to sustain us, and they're looking at bores. I think the next water supply is something like 25 kilometres away. They said they have to put in new generators because they'll need extra pumps to pump that water further. So building a new house isn't as easy as it sounds, and it's the same for workers as well as people who live in communities. If you want more services you need to have infrastructure for the services and rooms in clinics.

Yuendumu is a big clinic—it's the biggest in central Australia. We were wandering around the other day. We had so many visiting services that three of the regular nurses couldn't use their rooms and computers, so we were wandering around the corridor cleaning because we couldn't see patients because there weren't enough rooms. We have visiting services that we want to make the most of and get patients in, but there were also people in the waiting room who wanted to see us just for routine stuff, but we couldn't see them because there was nowhere to see them. Then there are smaller clinics that only have two clinical rooms in them, and things like that.

The other thing about housing is that workers everywhere—and I think community people, too—demand things like safety and reasonable housing, so it's not all about money. Professor Boffa was talking about salaries and things like that. There are reasons why people work in remote communities, but you have to have safe housing. You have to have housing where the locks actually work. There are a lot of dongas out there. They're old buildings on stilts, which need a lot of maintenance. People say, 'We don't we don't have to work like this. There are other opportunities—other work.'

Senator O'NEILL: Are communities growing? Lots of children are being born; we hear about this, but are communities growing? Is housing a pressing need because of that growth in communities or is it just that housing is just a pressing because it's never ever met the community need?

Mrs Byers : Housing has never ever met the needs in my experience of central Australia. That's why I reference to that. In central Australia every Aboriginal community that is here now was set up by either the missionaries or the Aboriginal protection authorities. In the sixties were the last ones. None of them were set up with any thought to sustainability or town planning, so they're all a bit ad hoc. I mean little towns grow elsewhere for reasons like that.

Senator O'NEILL: That's how Sydney started.

Mrs Byers : Yes, exactly. So it all grew a bit ad hoc, so now you're sort of playing catch up. People built things without necessarily—we didn't have the standards of quality assurance and things like that that we have nowadays. So you're playing catch up. You see that with hospitals and big public buildings, as well. By the time the new ones are finished they're out of date. I think it was never really set up in a planned model, and that's part of the reason. I'm not so convinced that communities are growing. I think there is a lot of transientness and there are some reports—I know the department of transport did one a few years ago about the Barkly region. There's a lot of transientness around Aboriginal communities, and there are lots of reasons for that. A community might grow for a while and then it will shrink and then it will grow again. I think you need to look at long-term figures to get real ideas of that. I know the Northern Territory population overall in the last census had gone down a little bit, and we need to grow the population in the Northern Territory, anyway. I'm not convinced that communities themselves are growing. You could take Bonya, which is up on the Plenty Highway, as an example. It used to have about 80 to 100 people and has dropped down to about 30. But down the other end of the Plenty Highway Engawala, which had a small community, has grown markedly, so services have had to move from one to the other. So I think it's more about that, from what I've seen, rather than just a population explosion. We have got a young population. You don't need me to tell you all that.

Some of the other reasons about accessing health services are, as the others were talking about, being culturally appropriate—and having interpreters. One thing I really liked when I worked in mental health with the government was that we did pay. The team that I was in—the remote mental health team—paid for interpreters to come with us and we expected interpreters to come. There were not enough interpreters, and we didn't always get them. I would book them but they wouldn't always be available to come. The small team that I was in had an absolute focus that you must. With somebody whose first language is not English, the fact that they've got reasonable functional English to do their shopping and what have you does not mean that they can understand complex mental health problems, and it also doesn't mean that they can understand the mental health system: do they really understand what a community management order is and things like that. If you're talking about guardianship, do they really understand the constraints that that puts on their life? So I do think interpreters are absolutely precious. I think the mental health services that are really enmeshed and contextually appropriate are the ones that are going to help people to access it.

The point of access is a really big problem. For very remote areas, it's generally when there's a crisis. There's very little you can do about it prior to a crisis. We know families come and say to us and ask us. There's no respite; I think that's what the girls at Yuendumu said to make sure I told you. We've had people and families come and they're really tired from looking after this person. You'll hear this for families with people in Sydney and things like that. They're really tired looking after their family member. They want help. It's not until the person that's unwell is attempting to hurt someone or themselves that you then get them admitted. Was that the best thing to do? I don't have easy answers for that. I do think some of the preventative services are important.

The previous presenters talked a bit about suicide. As far as the suicide rates in very remote areas are concerned, a lot of the stuff that I was taught as a mental health nurse isn't particularly useful, because you're often taught that people think about suicide for a long time and they might make a plan, start tidying up their lives and things like that. There was a suicide response group when I was working in mental health that was made up of a lot of NGOs and the government, and I was on that for four or five years. Really, when you looked at the very remote deaths by suicide, as Christine said, there was always some sort of relationship problem. It might have been an argument with a significant other such as a parent, a sibling or a girlfriend or boyfriend. Sometimes alcohol and other drugs were involved, but not always. But there was always some sort of relationship problem, and a lot of them were very impulsive. People said, 'I'm just going to hang myself,' and did, as opposed to this idea of a plan and that sort of stuff. Some people do have plans and talk about it and do it, but there is the impulsivity. So the stuff that I was taught in mainstream wasn't particularly useful about that.

It's difficult to evaluate programs that prevent suicide, because it's difficult to measure them. John Boffa talked a lot about outcomes and evaluations and stuff like that, but it's very difficult to say how your program prevents suicide any better than that one prevents suicide and that sort of thing, because you can't ask people who have died.

There are a lot of registers. The thing about having a suicide register has come up right through this thing. There are actually a lot of registers. They're mostly internal and dependent. I know NPY are holding their own. Nganampa have their own. The Department of Health's remote services were holding their own for a while; I think they just found that they didn't have resources to maintain it. I think MHACA, which is the Mental Health Association of Central Australia, were holding something for quite a while. A paper was published through the Centre for Remote Health about suicide in Central Australia and how to respond and that sort of stuff. When they were looking into that we actually found—oh, the police have one. There are a vast number of internal suicide registers. There's also quite a lot of difficulty about defining attempted suicide and potential suicide. I think that's part of the reason why it just got into a 'bigger than Ben-Hur' sort of thing and people just started doing their own.

In your terms of reference you had the nature of the mental health workforce. In very remote communities, as Martin Kelly said, it's pretty well generalist nurses who are supported by visiting fly-in mental health staff. It's mostly fly-in mental health nurses or psychiatrists. There are virtually no psychology services in very remote areas. I think the alcohol and other drugs service we have in some of the communities sometimes employs psychologists. They're primarily alcohol and other drugs psychologists.

There was an excellent thesis written by Scott Trueman, who is based in Queensland. It looks at registered nurses caring for mental health clients in remote Australia. That's a really good thesis. It gives you an overview of the different specialties that are out there and the problems. I can send that to you if you want.

CHAIR: Okay. If you could send that, that'd be great.

Mrs Byers : Yes.

CHAIR: I'm going to have to ask you to start winding up.

Mrs Byers : Yes, sure. If you want to ask any questions or whatever, just—

CHAIR: We've been asking them as we go along. We've been interrupting you.

Mrs Byers : That's fine.

Senator O'NEILL: You've been working your way through a good list there.

Mrs Byers : That's all right. We certainly need more Aboriginal health practitioners. John Boffa was talking about a pathway for clinical psychs; we need that for the Aboriginal health practitioners. It's a really big area. It's an area that could be really boosted up for very remote areas. Where you have two Aboriginal health practitioners, like in the mental health team that I worked with in remote areas, it's absolutely invaluable. There were some people out in the communities who were really interested in that area. There was no pathway for them through the government—and you've got to remember it is the government that provides these services in very remote areas. There was no real pathway for them to actually progress that, unless they had formal qualifications. But sometimes, like Christine said, you don't necessarily need that, but you do need that brokerage service.

Youth services and youth workers pick up heaps of the load, and that is generally in the preventative area. So they need to be supported and they need things like CRANAplus Bush Support Services so that they themselves are mentored.

The challenges of delivering mental health—you've probably heard a lot about that. I just can't understand it, because I like walking around and talking to people, but services within the government are very much siloed. One of the reasons that I went off to work in mental health—I'd been a remote nurse for a long time and then I was conned into working in mental health—was to learn about it. I went to learn about it. When I actually hit mental health, I couldn't believe how solid it was inside itself. I thought, 'No wonder a remote nurse can't understand'—because we used to evacuate people; they'd disappear into a big black space and then you'd see them wandering around, back in the community, two or three weeks later. It wasn't till I went and worked in mental health that I managed to figure out why this was so.

There is value in having jobs and positions where people are communicators, if you like, so they can talk to the non-government services and to the government services, and they can then understand what each service's roles and responsibilities are. I was seconded by the office of the chief medical officer in the Northern Territory a couple of years back to write a report about mental health services in Central Australia—which I can send you if you want—

CHAIR: Please.

Mrs Byers : and that's basically what it boils down to. There are heaps and heaps of people with very goodwill working at cross-purposes: 'I thought what you did was this, and you thought what I did was that, and it wasn't.' It isn't an acknowledged role, but I think that communication would fix a lot of problems. So I can send you that report.

Senator O'NEILL: Is it mental health nurses that would fulfill that role?

Mrs Byers : It doesn't have to be. You just need a good communicator who can actually do that work. I just call them coordinators. They could be social workers. They could be Aboriginal health practitioners. But it needs to be an acknowledged role within services, because, if you're not in a role where it's part of your job description—a very important part of your job description—you end up doing clinical work.

CHAIR: Yes. It's the same thing we heard yesterday. Everybody thinks everybody else is doing this or communicating that, when in fact nobody is.

Mrs Byers : Yes. Everyone's so busy doing what they've got to do, because of their funding or what their mandate is, that nobody's got time to be that sort of oil between all the services and say, 'This is what needs to happen.'

We talked about the attitudes towards mental health services. The others have talked to you about that. It's quite stigmatised. There's definitely a lack of understanding of services. When I worked in mental health, I used to spend a lot of time with age, disability and lots and lots of other services to clarify what we all did, to get the best for that individual patient: is this the right place for them? The cultural context is absolutely crucial, and the living context too. You have to understand what a very remote community's like—how difficult, what it means. It's no postal service. It's a nurse who's on call for 24 hours. When I'm on call from eight in the morning, I'm on call till eight in the morning the next day. So I can work an eight-hour day and then, if you ring me up at six o'clock, I'm still on call. I could be up all night until eight o'clock the next morning. If you don't understand that, you won't understand why I'm bit grumpy when you ring up to say, 'I've run out of tablets.' It's because I've already worked a full-eight hour day and you're ringing me up and saying, 'I'm not feeling too good because I've run out of tablets.' Why are you ringing me up after hours about that sort of thing?

So, if you don't understand the context in which people work and live—like the fact that their water doesn't taste too good and it's hard to get—you can't really deliver good services.

CHAIR: Can I—

Mrs Byers : Should we finish? Just cut me off if you need to.

CHAIR: You've got about a minute left.

Mrs Byers : We talked about technology. Martin talked about the therapeutic relationship. I think that's crucially important as far as telehealth goes, because there's a big push to use telehealth. You absolutely need a therapeutic relationship first, and it's no substitute for face to face. You also need to look at the dangers if we're pushing more people online. There's some stuff about professional development, like upskilling generalist nurses and stuff like that, because that's what you've got out there. If you push more people towards online—communities are going to online, and I don't think it's come up much. There's a good report that's just been put out by Telstra about cybersafety in remote communities. I found it a bit horrifying. The researchers came from Swinburne University of Technology. You've got children of eight or nine filming community fights and sharing these on Facebook and stuff like that. You talk about the violence that people live within and what's normalised.

Telehealth has certainly got its place and we want to use it, but you also have to have the infrastructure in place to support it. We had one case where a patient left the room and then another patient wandered in. It was so pixelated that the doctor that was talking to them couldn't tell it was a different patient. We had to say, 'Stop, you're talking to a different person now.' So you have to have that underlying infrastructure before telehealth is going to be effective.

Senator O'NEILL: They need to receive it in clinics with you beside them, really, don't they?

Mrs Byers : Yes, but that requires a clinic room and a nurse or a health worker or someone. To be really effective and useful in remote communities—

Senator O'NEILL: Then it's a training opportunity as well.

Mrs Byers : Yes, but the nurse really needs to go out a week before the specialist is going to be there and round up the people. People were talking about stigma. That is literally what happens. It's a walk-in clinic. How do people who don't speak English and don't get mail and what have you know that that specialist is coming? There are not admin people, so that's me. If the hospital sends out an appointment saying, 'You have got a telehealth appointment next week at two o'clock on such and such a day,' I have to stop doing the clinical work, go out, find that person and say, 'Is that going to work?' They might say, 'No, we're going to be at a funeral.' We have to cancel that, rebook that and so forth. Are they going to make their way to the clinic, or do I have to? It's resourcing. Was there anything specific?

CHAIR: That has all been really useful. Thank you. You've got a number of papers that you mentioned that you're going to send to us.

Mrs Byers : Yes, I can send them if you think they'll be useful.

CHAIR: Yes, they definitely will be. The secretariat will be in contact with you about how we get hold of them. Thank you so much for your time today.

Mrs Byers : No problem.

CHAIR: I really appreciate it. Thank you for the notes.