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Community Affairs Legislation Committee

COWLING, Dr Brett, Chief Executive Officer, Ngaanyatjarra Health Service

GILES, Mrs Nerida, Private capacity


CHAIR: Welcome. Thank you for giving your time and thanks very much for joining us. We really hope that you are going to share your knowledge with our committee. You have information about parliamentary privilege and the protection of witnesses. Do you have any comments to make on the capacity in which you appear?

Dr Cowling : I am the CEO of Ngaanyatjarra Health Service, which is the same group as you were previously talking to. We are across those same Ngaanyatjarra lands as part of Ngaanyatjarra Council.

Mrs Giles : I am an Aboriginal health worker from Tjukurla.

CHAIR: Would either or both of you like to make an opening statement before we go to questions?

Dr Cowling : Yes. I guess you have a bit of a picture of where the Ngaanyatjarra lands are. You have heard from the previous people about the remoteness. It is the largest primary healthcare service provider in the country in terms of geography. In terms of remoteness, there are some really big challenges there, but none more than that 40 per cent of the population would elect to come back across the border as patient flows to the east. That is particularly problematic in the absence of tri-state agreements allowing them to do that. We can talk about that throughout the session.

We are based in Alice Springs. Nerida has been an Aboriginal health worker in the Tjukurla and Jameson communities for greater than 20 years, so she brings a lot of on-the-ground experience and can answer some of those other questions about petrol sniffing rates. We would like to present a primary healthcare perspective on some of the implications for mental health in particular, how it relates to cross-border patient flows and what is happening on the ground from the perspective of clinicians—psychologists, social workers, mental health practitioners and GPs—who I manage as the CEO of Ngaanyatjarra Health Service.

CHAIR: I should warn you that at the end of our questions about Opal fuel—and I know your points have been very much taken up by the senators—we will be throwing a couple of questions at you about palliative care. I just thought I would warn you before we started.

Senator SIEWERT: We multitask around here. You said you wanted to make some comments about the mental health impact, and I know Senator Smith is very interested in the mental health aspects as well. I presume you are endorsing all the other comments that have been made, that with the broader rollout of Opal fuel you have also seen a significant drop in people petrol sniffing. Is that a good starting point?

Dr Cowling : On the Ngaanyatjarra lands, I think it is too early to look at the data on reductions in petrol sniffing. I think over a long period of time there have been various efforts at harm minimisation, not just the rollout of Opal fuel, and those things have inevitably led to a reduction in substance misuse on the Ngaanyatjarra lands. I think we will see data emerge following the change in Laverton. You have spoken about that already today.

From a mental health perspective, though, we are really only beginning to scratch the surface of service provision. Part of that is that Ngaanyatjarra Health Service is not specifically funded to provide mental health services. They sit with the Medicare locals that operate out of Kalgoorlie and Geraldton and for many years there has just been a fly-in fly-out service from Kalgoorlie to the Ngaanyatjarra lands some thousand kilometres further west. That is a particularly problematic, challenging way to deliver a mental health service to people on the ground.

It has really relied on clinicians, GPs, Aboriginal health workers and nurses without those specific mental health clinical skill sets to deliver that service. Yes, we can talk about that, if you like.

I have begun a conversation with the Mental Health Commission in WA. I had the opportunity to meet with Helen Morton on two occasions. Minister Morton came out to the Ngaanyatjarra lands recently to get a better picture of some of the mental health problems and some of the suicide rates in communities such as Kiwirrkurra—you are probably aware of some of the issues there—and especially those communities that are very close to the borders with the Northern Territory and South Australia and are not included in the service delivery out of Kalgoorlie because of the distance. They are naturally not in the contact.

Senator SIEWERT: So who are they being serviced by?

Dr Cowling : They are being serviced by Ngaanyatjarra Health Service, which is funded to deliver primary mental health services. We, out of a very small allied health budget, have a social worker as part of our team. We work collaboratively with the newly established Medicare Local in the Kalgoorlie Goldfields district to try to utilise that service as much as possible. That is an ongoing challenge and not pragmatic to deliver in a fly-in fly-out model.

Senator SIEWERT: We heard this morning from NPY about somebody going up to Kiwirrkurra on a fly-in fly-out basis every six weeks.

Dr Cowling : Yes.

Senator SIEWERT: I want to come back to the mental health issues, but I just want to establish the numbers around petrol sniffing. What we heard this morning from NPY is that there is still petrol sniffing, that it seems to be most persistent still in your lands and that a large number of people have had some contact with petrol. We were told this morning that 60 per cent or 70 per cent of those under 25 have had some contact with petrol sniffing. Would you—

Dr Cowling : Yes, although NHS do not collect petrol sniffing data specifically. NPY and Ngaanyatjarra Health Service work closely together.

Senator SIEWERT: I will come back to the bill, but I am trying to establish some other baseline data on how that is related to the causing of ongoing mental illness and why people are abusing substances in the first place.

Dr Cowling : Thank you; you have picked up on a really important, and that is the overall holistic wellbeing of a community and what other therapies are in place. This is not a new issue. Those things are being tackled by organisations such as NPY. You would have heard some examples of that this morning.

In terms of mental health, it is a given that there are flow-on effects from substance misuse to mental health. That is well evidenced based. The Ngaanyatjarra lands are no exception to that. From that 60 per cent or 70 per cent, you would probably find that the majority of the mental health clients that we have seen have had contact with substances. It would be by far the majority. That would not be any different to any mental health data in other locations. It would be on different substances but it would be consistent data.

Senator SIEWERT: But the issue for you is that the community is not getting the level of funding to provide proper support for addressing mental health.

Dr Cowling : That is right. We are talking about a few different issues, such as acute mental health first aid. Yesterday, for example, there was another suicide attempt by a 21-year-old in Kiwirrkurra and a remote area nurse was required to attend that with very little support from a qualified mental health person.

This is a community that has a suicide attempt every couple of months. There is documented evidence from NPY on their work in this area; they may have mentioned it this morning, I am not sure. But on a regular basis there are issues around mental health service provision. Then you have got the ongoing issues around social work and social welfare, and the work to try and break the cycle that is ongoing, not just to provide mental health first aid.

Senator SIEWERT: One of the issues around the social support, and the ongoing support, that we heard about this morning was that the support for case management is not as effective in Western Australia as it is in, say, South Australia and the Northern Territory—the funding is not available to do that more intensive case management.

Dr Cowling : Yes, the funding is not available, and as a result of that it is a real issue to have people on the ground to manage these cases in the remote sector. We have looked at other technology and at having staff trained to use videoconferencing, and at linking those people in with tertiary facilities and psychiatrists, but there is a lot more work required. All of those things are being addressed in a small way, given the extremely finite primary healthcare dollar that is available to deliver this service not targeted at mental health.

Senator SIEWERT: Sorry, are the dollars not being targeted at mental health?

Dr Cowling : They are not. We have a federal bucket of money from OATSI for primary health care—

Senator SIEWERT: And you are trying to stretch that.

Dr Cowling : and trying to stretch that to cover mental health services is a significant issue.

CHAIR: And meet the requirements attached to that money.

Dr Cowling : Correct.

CHAIR: Because you are reporting back and you just do not have the funding for the mental health stream.

Dr Cowling : That is correct.

Senator SIEWERT: I want to ask one more question around Medicare Locals, and then I want to go back to a couple of specific questions about access to fuel and petrol sniffing. You have mentioned several times now that you have started a dialogue with the Kalgoorlie end of the Medicare Local—and it is just as well that it only goes up to around Geraldton, because it was going to be the whole of the rest of Western Australia outside the south-west of Perth. How is that progressing to date?

Dr Cowling : The dialogue is ongoing. I chair the Goldfields regional forum—the COAG Regional Aboriginal Health Planning Forum—to make sure that we have a strong presence in the Goldfields region, recognising that the Ngaanyatjarra lands, despite their large geographic area, are pretty easy to forget in WA because of the patient flows this way. I guess that is where I would like to pick up on the tri-state stuff a little bit later.

Senator SIEWERT: Actually, can you talk about the tri-state agreement? I have had some involvement with that when we went over the dialysis, and that was very interesting.

Dr Cowling : So you have heard from Sarah Brown, this morning or yesterday perhaps?

Senator SIEWERT: This morning.

Dr Cowling : Sarah and I have worked closely on delivering remote renal services. Obviously, it is not core business for a primary healthcare service provider, so linking into a renal provider in that way is essential. What that means is that those services have to work cross-border as well, and they come under different legislation and different licensing requirements in WA. There are three locations on the Ngaanyatjarra lands that are moving towards having renal dialysis services managed by the Western Desert Purple House mob. That is moving forward.

I have recently had discussions with Minister Snowdon about the meeting he had three weeks ago now with the three respective state health ministers about progressing that renal tri-state agreement. That is still an ongoing challenge and it is not resolved as yet. There are efforts being made in the Top End to provide those beds at Darwin Hospital. There is a contribution made to Alice Springs Hospital to provide renal services for Ngaanyatjarra people here, and I acknowledge that effort.

The report that was written by Alan Cass really looked at the preference of the people to have the services delivered closer to home. When we are talking about communities such as Warburton, which is 1,000 kilometres from Kalgoorlie and 1,000 kilometres from Alice, it is probably not reasonable to expect those people to travel that far from home and have that.

Senator SIEWERT: Dialysis is not the only health issue that you would have tri-state issues with, is it?

Dr Cowling : No. Renal is probably the most costly issue. The next biggest one—Nerida may like to pick up on this one—is around the choice of women to deliver and come to Alice Springs for sit-down. This is a particularly big challenge; there are only a couple of communities that have the option of doing that: Tjukurla is not one of them, despite its proximity to Docker River and Kintore, where those family groups are. Then there is the RFDS issue, which also needs to be resolved as a component of that. Nerida, would you like to say anything?

Mrs Giles : You're right.

Dr Cowling : She is just agreeing with what I have said.

CHAIR: Mrs Giles, in terms of the women, and we have had this discussion before in Alice Springs about women having to leave home to have their babies, what are the concerns they raise with you?

Mrs Giles : They don't know what they are worried for. They've got no families at Kalgoorlie. It is hard for them to stay there and to come. When they finish hospital it is hard for them to travel back down. They come as far as Warburton and there is no family there to take them back to my community.

CHAIR: How far before their baby is due do they have to leave home?

Mrs Giles : When they are ready they go and stay there for three or four weeks.

CHAIR: It is a long time to be away from home. What happens when they come across? Is there anywhere for them to stay? We have had this discussion before in this committee.

Mrs Giles : There is a hostel. There are a lot of Aboriginal people around, especially people from Warburton, from Ngaanyatjarra lands, and some have no families to go there and stay.

CHAIR: How much does it cost for women to come so far and then get home? Does it cost a lot of money?

Mrs Giles : Yes.

CHAIR: Does the health service pick that money up, Dr Cowling?

Dr Cowling : The majority of that funding is covered by the patient transport scheme. A bigger issue sits with Aboriginal Hostels Australia and the limited number of beds: they are extremely finite in Alice Springs. Even if women are from one of those Western Australian communities that do have the ability to come across the border, such as Kiwirrkurra, often the bed is not available for an ante-natal woman to come and sit down for that three or four week period that Mrs Giles which is referring to.

CHAIR: There is just no option.

Dr Cowling : That is correct.

Senator SIEWERT: Going back to access to sniffable fuel that is still associated with petrol sniffing, we have heard that there is ongoing access to fuel coming into communities from Kalgoorlie. Is that consistent with your experience?

Dr Cowling : Mrs Giles is saying that it comes in from Laverton from the Kalgoorlie end.

Senator SIEWERT: It comes in via Kalgoorlie, via Laverton and across.

Dr Cowling : And across from there. Obviously the rollout in Laverton has reduced that. An important discussion that has been happening with Minister Morton is the implementation of that piece of legislation in WA as well and what would be the implications of that and the empowerment it would give to WA police to act given that—

Senator SIEWERT: Transporting petrol is not illegal.

Dr Cowling : Yes, that is right.

Senator SIEWERT: How have your discussions with the minister been going?

Dr Cowling : They are ongoing. She is very receptive to the issue. I was extremely impressed by her time on the ground in April. She spent five days on the ground on the Ngaanyatjarra lands, travelling by road to seven of the 12 communities that make up the Ngaanyatjarra lands. I think she firmly got her head around what some of the issues on the ground are, including some of those other issues around diversional therapy and where this may lead to in the future in terms of the broader mental wellbeing of Ngaanyatjarra people.

Senator SMITH: Earlier you mentioned the cross-border flow from west to east. You mentioned that Warburton is 1,000 kilometres away from Kalgoorlie and 1,000 kilometres away from Alice Springs. Is it a cultural thing or is it just a proximity issue?

Dr Cowling : All of the above. There are cultural aspects and there are family aspects to this decision. Some families, such as Nerida's family for example, have more support in Alice Springs. None of her family would elect to go further west. But there are cultural aspects as well in there, and I have heard some stories, which I am not entitled to share, around the more cultural, traditional aspects that would prevent people from going further west, including about those issues and beliefs that some of the illnesses have emerged when people have been forced to be on land that is not their own and be in places and spaces where they are not welcome. So there is a strong cultural, traditional belief around disease process from that perspective.

Senator SMITH: You also talked about mental health issues as a consequence of petrol sniffing. Is a young person more inclined to be a petrol sniffer if they have some pre-existing mental health issues?

Dr Cowling : I do not know the data on that. The indications that we have got are that people are beginning to sniff petrol at very young ages, before you would actually have a mental health diagnosis anyway, so it is difficult to respond to your question.

Senator SMITH: In your experience, what is that age range? How young are we starting to get to in the communities that you are involved in?

Dr Cowling : We are aware of some children in the eight to 10 age bracket who are experimenting with substance misuse—not only petrol, but other volatile substances as well. That is at least four or five years before you would be able to establish a mental health diagnosis with that client group.

Senator SMITH: We heard earlier today from the NPY Women's Council. They said they had some anecdotal evidence that 60 to 70 per cent of people under the age of 25 had been involved in petrol sniffing. Would you concur with that?

Dr Cowling : I stated previously that that is consistent with our data. We work quite closely with NPY on this issue and I would say that, certainly in some communities, that is consistently relevant data. For example, I have looked at the NPY data from Kiwirrkurra and it certainly was consistent with the Ngaanyatjarra Health Service data.

Senator SMITH: How necessary would it be to mandate Opal fuel in a town like Kalgoorlie in order to put an end to some of the petrol sniffing issues specifically in communities like Warburton?

Dr Cowling : I think it is essential. There are probably several strategies which need to be addressed. Harm minimisation is by far the most important initial one. Having options for rehabilitation in places for where Ngaanyatjarra people or remote communities will willingly attend and stay is also important, as is ensuring they are not getting rehabilitation in places like Kalgoorlie or Alice where they may get caught up in the cycles of substance misuse and vulnerabilities there.

CHAIR: Can you tell me why it took so long to get Laverton to use Opal? That might be a really dumb question but 10 or 15 years ago there were a few communities which did get national coverage about how bad petrol sniffing was in those communities and one of those was Warburton. I am not sure why it has been only two or three months since Laverton got onto the Opal process. Do you know why it took so long?

Dr Cowling : My understanding is that it was as a result of the provider there being reluctant. I am certainly aware that when Minister Snowdon took a strong stance on this, it did happen and the rollout was implemented at that stage, but you are right; it did take longer than it should have, given the data we had in the early 1990s about remote communities, especially Warburton, and three of four substance misuse related deaths which happened at that stage.

CHAIR: And the identification of the zone early covered that whole region in terms of coverage on the map—WA, Northern Territory and South Australia? It means that that whole region is now several years behind the rehabilitation process of seeing how it works.

Dr Cowling : That is correct.

CHAIR: It is also difficult to look at the impact. We know that if we model that area against the impact we have seen so far in this part of Central Australia, it is very positive to see what will happen once it is imbedded but you are so early in the process that it is at the hopeful stage rather than reality. Is that right?

Dr Cowling : That is correct.

CHAIR: As there are no further questions on petrol sniffing, we now turn to questions on palliative care.

Senator SIEWERT: This morning we had congress, Purple House, Sarah and Northern Territory Palliative Care present extremely useful evidence to our palliative care inquiry, but they mentioned the services which both NPY providing and you provide. We are interested to find out what services you provide, what are the key things that you do for community and particularly how your address cultural issues. One of the things that came out this morning was that palliative care services need to address cultural issues. I think it would be fair to say that that is a work in progress.

Dr Cowling : There are several issues there. The first one is that with the high rates of renal disease which we have, it is essential to have a choice in palliative care in the remote sector.

I do work closely with those three people whom you heard from this morning. Historically, it is not a strong component of primary healthcare service provision but, with the escalation of renal disease, it absolutely needs to be. We have some 328 people at some stage of renal disease on the Ngaanyatjarra lands. That is a significant percentage of the population who will need to face that choice of support for renal services or support for palliative care.

We work closely with the renal service providers to the west and in Kalgoorlie, as well as to the east from here. That also incorporates giving patients the option to seek treatment wherever possible in alternative places, in Alice, Kalgoorlie or Perth, and also to get support for palliative care. There is very good funding through MSOAP, whereby we access 22 different specialist visits per year to the Ngaanyatjarra lands. That is nearly one every fortnight to various specialty areas. That targets specifically those with chronic diseases excluding mental health that are particularly problematic on the Ngaanyatjarra lands and that lead to—

CHAIR: There are four groups: renal—

Dr Cowling : Heart disease and often, as a result of rheumatic heart disease, you have lung disease and urinary separate to renal. We have a 52 per cent rate of chronic disease on the Ngaanyatjarra lands, if you are just looking at the data from those four diseases.

CHAIR: Is diabetes—

Dr Cowling : Included in the renal—

CHAIR: So diabetes is linked into the renal area. Okay. I had heard of some stats about your region and diabetes was really high.

Dr Cowling : They are all documented in the Central Desert renal report that you would be familiar with.

Senator SIEWERT: Where do you access the 22 specialists that you get?

Dr Cowling : By far the majority of them are Perth based specialists that fly up on a weekly charter and visit hubs of services around the Ngaanyatjarra lands. They probably visit three or four communities regularly, three to four times per year per specialty area.

Senator SIEWERT: That will be to those four key specialty areas, as you said. In terms of palliative care, are you able to access palliative care specialists?

Dr Cowling : I might add that palliative care is not one of those specialty services.

Senator SIEWERT: Are you able to access palliative care specialists?

Dr Cowling : In terms of patient flows the only option is for a patient to go to Kalgoorlie and get assessed and then to look at returning to our aged-care facility, which is not geared towards palliative care. It does not have a palliative model. But for low-risk care we can provide some services at that facility.

Senator SIEWERT: Where is that located?

Dr Cowling : That is in the community of Wanarn.

Senator SIEWERT: You can provide some palliative care there, even though it is not—

Dr Cowling : With the support of the team from Kalgoorlie.

Senator SIEWERT: So do other people who cannot access that particular facility end up having to go to Kalgoorlie for palliative care?

Dr Cowling : Yes. Or a lot of them will opt not to go anywhere and to palliate with GP support on the ground and with remote area nurse support. That is less than optimal both for the clinician and the client.

Senator SIEWERT: I presume therefore these are the same issues about which we had quite lengthy discussions with all of our witnesses this morning not only about the complexity of being in the community and at home, trying to access palliative care services, but also around cultural sensitivities?

Dr Cowling : Yes, there are significant issues that need to be addressed by skilled, culturally appropriate palliative care clinicians. That is something the team you heard from this morning do particularly well in Alice Springs, even as an outreach to remote communities, and they work particularly closely with those service providers targeting chronic disease such as renal. Certainly the service provision from the west is not as well geared as it is from Central Australia to do outreach service provision.

Senator SIEWERT: Okay, but are there some outreach services from the western side?

Dr Cowling : Not to the Ngaanyatjarra lands, no.

Senator SIEWERT: So they rely totally on the east?

Dr Cowling : Correct.

Senator SIEWERT: They do not provide any funding to help from the east?

Dr Cowling : No.

CHAIR: So that cross-border arrangement we have been talking about that is so critical for these areas operates in the renal area but, for other areas—

Dr Cowling : It operates in the renal area—

CHAIR: To some degree.

Dr Cowling : to a very small degree. There have not been new renal patients cross-border from WA since 2007.

CHAIR: We did not know that.

Dr Cowling : That is just covering the 11—it was 12 but is now 11—WA residents living in Alice Springs to get renal service provision here both through Flynn Drive and through the Purple House.

CHAIR: But there are no new patients coming across.

Dr Cowling : None have come across the border since 2007.

Senator SIEWERT: Where are they going?

Dr Cowling : They go to Perth and to Kalgoorlie. There are no beds in Kalgoorlie and have not been for several years.

CHAIR: They are all full.

Dr Cowling : They have been full. They have been at capacity for a number of years, so new patients elect to go to Perth or elect not to get treatment with a finite palliative model of care.

CHAIR: As much election as that means!

Senator SIEWERT: Is the Warburton dialysis service up and running now?

Dr Cowling : The Warburton dialysis is not up and running. It has received a small amount of federal funding to get a renal ready room that was built in 2004 to be established. That is some minor works money to the value of $150,000.

Senator SIEWERT: Except for the nurse money.

Dr Cowling : It still requires a commitment for renal nurse recurrent salary. The Warburton facility comes under the WACHS service provision—WA Country Health Service. I am meeting with that team on a regular basis to move this issue forward. Then there is still an unresolved issue of housing and accommodation for those nurses. So it is moving forward. There is commitment from the federal government for minor works. There is commitment from the Ngaanyatjarra Health Service board, with some of the money that is received through royalties, but that is only to the value of about $30,000 or $40,000 per year.

Senator SIEWERT: Sorry; I know I am going way beyond, and I think we need to talk to you some more. How many renal—

Dr Cowling : Twenty-three.

Senator SIEWERT: Twenty-three have gone back to Perth now?

Dr Cowling : There are 23 Ngaanyatjarra residents that currently receive renal dialysis. Eleven of them, from pre 2007, are based in Alice Springs. The remainder have gone further west.

Senator SIEWERT: So have I got this right? There are 23, with 11 in Alice that were pre 2007 and 12, therefore, that are—

Dr Cowling : In Kalgoorlie or Perth.

Senator SIEWERT: They have been sent to Kalgoorlie or Perth.

CHAIR: And potentially more coming through that need the service.

Dr Cowling : We also know that there are more that have elected not to get a service.

Senator SIEWERT: That was my next question: how many have elected not to get a service because they did not want to go to Perth or Kalgoorlie?

Dr Cowling : That is very difficult to determine. People do not like to be upfront about that decision. I do know that there have been people that have opted not to get care at all. If there were service provision closer to home, they might have—and anecdotally I would say they absolutely would have—opted to have care on the lands closer to where they live.

Senator SIEWERT: I will make this the last question. I thought WA had coughed up—sorry, I should use technical terms—or given some money to the Northern Territory, but that was for existing patients, not new patients. Is that—

Dr Cowling : That is correct. My understanding is—and this is from Ian Smith, the CEO of WACHS—they give $2 million per year to support service provision to WA residents living in Alice Springs receiving haemodialysis.

Senator SIEWERT: But not for new patients.

Dr Cowling : It is the ongoing care of those 11 people.

Senator SIEWERT: Okay. And that is limited because WA will not now pay for new patients, not because of bed availability?

Dr Cowling : Is there bed availability here—is that your question?

Senator SIEWERT: I suppose so, yes.

Dr Cowling : Yes, there is.

Senator SIEWERT: Thank you.

Senator SMITH: Dr Cowling, from your evidence and what we have heard from other people there seems to be a serious gap in the level of services provided in Western Australia by the state government in your community. I take on board what you have said about the visit of the minister et cetera, but it is across a whole range of areas now. Would that be a fair comment? I do hear you are in constant discussion with them; but, that said, it does seem there is a bit of a gap between the level of service provision in Western Australia for the community you represent and the level provided in the Northern Territory.

Dr Cowling : In fairness to the Western Australian government, they would argue that primary healthcare service provision is the core business of OATSIH and, therefore, those services should be provided by Ngaanyatjarra Health Service, funded through the Department of Health and Ageing. The difference is that, with regard to the Warburton facility—which historically was funded by the Office of Aboriginal and Torres Strait Islander Health in WA and transitioned to WACHS three or four years ago, to the value of $1.6 million per year—they fund for the primary healthcare service provision in Warburton only. That is because it was a WACHS run facility before it was managed by Ngaanyatjarra Health Service.

Senator SMITH: Thanks.

CHAIR: So, taking up Senator Smith's point, the need for further focus and funding for your region could be shared by the Western Australian government and the federal government?

Dr Cowling : Absolutely—and I would like to see further collaboration and discussion at a COAG level. I have taken a lead in chairing that regional forum and sitting on the WA state planning forum so that there is a voice there to ensure that joint collaboration between the federal and state governments is optimal.

CHAIR: Dr Cowling or Mrs Giles, is there anything else you would like to put on the record that we have not been able to draw out by our questions?

Dr Cowling : Mrs Giles is saying 'palya', which means she is okay, thank you. And 'palya' from me as well.

CHAIR: Thank you very much. We deeply appreciate you coming today and the evidence we got.

Dr Cowling : Thank you for the opportunity and for coming to a rural, semi-remote setting such as Alice Springs.