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Community Affairs References Committee
Accessibility and quality of mental health services in rural and remote Australia

BAUER, Dr Renee, Clinical Director, Kimberley Mental Health & Drug Service

TRAN, Dr Huu Duy, Consultant Psychiatrist, Kimberley Mental Health & Drug Service


CHAIR: I welcome representatives of the Kimberley Mental Health & Drug Service. Can I just double-check that you've been given information on parliamentary privilege and the protection of witnesses and evidence.

Dr Bauer : Yes.

CHAIR: I invite either of you or both of you to make an opening statement, if you wish, and then we'll ask you some questions.

Dr Bauer : Thank you. Firstly, I'd like to acknowledge the traditional owners of this land, the Yawuru people, and their elders past and present. Thank you very much for inviting us to this hearing. I know you've already heard from our colleagues in central office, Dr Main and Ms Chatfield, and I believe they gave you some background on the Western Australian Country Health Service and our involvement in mental health. So we'll speak about and hopefully answer some of your questions specifically about the Kimberley region.

CHAIR: That'd be brilliant. Dr Tran, did you want to say anything?

Dr Tran : Likewise, I'd like to acknowledge the traditional custodians of the land on which we meet here today and pay my respects to the elders past, present and future. I really want to acknowledge that this is their country that we're on, these are issues that affect the local people here and it's the voices of the local people that are going to be the most poignant and representative, and we hope to contribute to that. So thank you for this opportunity.

Senator PRATT: I wanted to ask you both, in your clinical and professional opinions, how well the health services do up here in terms of navigating Western medical practice and the cultural needs of clients—everything from the kinds of screening tools that you might use to language barriers, and the social and cultural determinants of people's mental health—and how you as clinicians go about doing that.

Dr Tran : We do the best we can with what we've got. Many of us—most of us, for that matter—come from a training background, where we have been educated and trained and specialist trained through a Western framework in the conventional medical model. Much of that, of course, is applicable, but there's much of it we have to unlearn in order to address the issues that we face here in the Kimberley.

One of the one of the major issues that exemplifies that is the issue of suicide. Suicide is a symptom of many other upstream factors, as is substance use, as is poverty, as is having kids in custody, as is a high rate of incarceration. Those are the products of other upstream factors. You may have heard the analogy previously today about suicide and what we can do as frontline services. People who are at risk of or complete suicide have drowned at the end of the stream. If you give us more resources to catch more people with nets before they drown, then of course we will catch more people before they drown. However, that doesn't address the upstream factors.

When you take one immediate step back from the suicide or from the substance use, you'll find that when we do an analysis for people who have tragically taken their own lives, suicide is almost never due to a mental illness. So it's not due to something that we can diagnose and treat within a conventional Western model, within a Western framework of how our hospitals and our clinics are set up. Two of the big determinants, when you take one step back, are substance use or alcohol use and interpersonal conflict or social disruption. If you take a further step back from that, because those don't come out of nowhere, what's led to those is intergenerational trauma, the effects of colonisation and many, many years of successive government policies, however well-meaning they've been. We alone can't address all of those social and environmental determinants.

How do we translate our skills and knowledge to help in that space? One example with suicide is using our expertise to try to ascertain whether a person who is at risk of suicide is at risk due to mental health issues. Most of the time, the answer is no. Are they at risk, alternatively, due to substance use issues? Much of the time, the answer is yes, and we can intervene in that arena. If you give us more resources, we'll be able to do more in that space. Then there are social and environmental determinants which are beyond the remit and beyond the capacity of what we can do with our resources.

How do I use my training to connect with people? No matter how hard I try, I won't be able to engage with someone sitting in front of me as well as someone who is local. No matter how kind, how compassionate or how skilled I am, I won't get the level of engagement with someone who is in distress that a local person will get. That's where we're trying constantly to innovate and evolve our service to make it more accessible, higher quality and more meaningful, rather than just putting a bandaid on, fixing someone up, keeping them safe overnight and sending them back to the same scenario where they are at risk again, whether it's of mental health issues, suicide or poor health outcomes in general.

Senator PRATT: Thank you, that's a helpful statement.

Senator O'NEILL: I've got a specific question. A young woman in a remote community not too far from here attempts suicide. She is saved and cut down by an elder or a community leader just prior to completion. She comes to the hospital here and gets an acute treatment and then is returned to the community. How is that allowed to happen? What system failures are going on there? What cultural failures are happening that we can begin to think about in terms of access to service, access to support and changes that need to happen to better deal with that acute reality, let alone the causes that lead to it?

Dr Bauer : We can probably go through some of the events that sort of lead up to those situations. We have a unique program in the Kimberley with an arrangement with the Western Australia Police. For every person that is brought into the hospital emergency department with an episode of self-harm or even threats of self-harm—words only—we will receive notification of that. It does have some ethical concerns because it is without the consent of the person. Kimberley Mental Health and Drug Service will receive a very detailed police notification which allows us to follow up every person that arrives in ED with a self-harm attempt.

Senator O'NEILL: Is this process recently established?

Dr Bauer : No. It's in the last few years—probably in the last five years.

Senator O'NEILL: We heard some evidence this morning about significant changes in the information flow around this sort of presentation at ED only this year.

Dr Bauer : This has been going on for about five years. We get in excess of 500 detected incident reports every year into our service. We process and follow up every single one of them.

CHAIR: So that's into your service, not necessarily to the GPs?

Dr Bauer : I'll explain a little bit about process and what happens then. If somebody is brought into the emergency department and people have the feeling that hospitalisation is the best thing for them, that really depends on the assessment and the individual circumstances. There will be times when that isn't the best treatment for a patient. In fact, it can be quite retraumatising for clients to be hospitalised, particularly when they don't want to be. We certainly involve family. We have very good relationships with our emergency departments, and we have 24/7 on-call psychiatrist support after hours as well to our clinicians that work in hospital. So we can advise and assess any presentation either by videoconference or in person if necessary. It may well be that an assessment is made in the emergency department that they can go home with family. There would clearly be a lot of carer involvement in the decision as well. We will always follow up the Kimberley mental health service the next day and we will definitely involve primary caregivers.

We realise, of course, that our service—not many people first present to a specialist centre hospital. They usually come somewhere else first, whether it's primary care, another agency or the hospital. People do self-refer to us, but that would probably be a minority of cases. We prioritise partnerships with primary care and our NGO partners and government agencies as well. We certainly work very closely with CPFS around child protection issues and we have regular meetings around children and young people at risk. In that example that you gave, if a young woman has gone back to the community we will follow up and have an assessment in the community. It may involve a joint assessment with primary care or it may involve our triage. We have sites across the Kimberley.

Senator O'NEILL: If the incident happens on a Friday evening and they end up in hospital, and they're back in the community on Saturday, people from community are saying to us how distressed they are about that experience and how unprepared they are to deal with it. They want to, and they have this very strong sense of duty to care for family, but the skill sets are absent and they don't seem to see a way of making up that skill set. So there's the Saturday, and all the other stuff that's going on in the community around it—the risk of a repeat on Sunday. When do they see somebody? Especially if it's somewhere like Balgo.

Dr Bauer : As Rob indicated, we work very closely with primary care clinics who have a 24/7 service in the remote communities. So there will be access to care. Those clinics, indeed, have access to us, not necessarily in person at a place like Balgo, but access to telephone or videoconference support.

Senator O'NEILL: So families in crisis actually have 24/7 access to somebody in every remote community that you look after?

Dr Bauer : Yes.

CHAIR: That's not what we hear.

Dr Bauer : The manned health clinics will have a nurse on call who can ring. That do not they choose to ring us is another matter, I guess, but we're available.

Senator O'NEILL: Whether they're available, even though it's supposed to be on call.

Dr Tran : To answer one of your first questions about how that is allowed to happen—how is a person who is already deemed high risk and almost lost their life allowed to go back to community. We ask ourselves that every day. One of the huge reasons is that the health professions and the health system can only play a small role. We're only a small part of this bigger puzzle. If there is a compelling health reason to keep someone in hospital, then yes, of course we will do that. That's our duty of care and it's our ethical, personal and professional obligation for that person to be physically safe, to have their wounds addressed and to assess whether there is a mental health reason to ask that person to stay in hospital, with collaboration with the family. Yes, if there is a reason we'll keep that person in hospital. However, a hospital is an institution. It's a conventional western institution that's a traumatising place. It's not in community. What you will have heard today is that people do not feel safe, do not feel secure, do not feel supported in an institutional environment. As Dr Bauer was saying, that will often make things worse. And we don't do it proudly and we don't do it lightly, but to first do no harm, and in order to respect the strength of the culture and the power of the community then we have to mobilise everything we can. It's not perfect, but we do our best to mobilise what we can to bring that person back to somewhere that's therapeutic, and the hospital is not always or not often the place.

To answer some of your other questions, is there someone on call 24/7? Yes, of course there is. We have services to provide that. But are we the right service? The instances when we get the best engagement and the best outcomes are when we've been able to empower local people on the ground. When I take a step back in the consulting room, rather than me driving that and rather than me being a top-heavy, medical-down practitioner, if I've asked a local person who can build a bridge between me and the distressed person rather than me inadvertently retraumatising that person by grilling them with interrogative questions, the person who's there building the bridge, the Aboriginal person, makes it a safe interaction and allows that person and their family to buy in to the strategies that will most likely make a more meaningful and enduring difference, and that those strategies are not tablets. We could we could throw as many tablets at people till the cows come home, medicate people to the eyeballs: it will not address the upstream factors that have pushed people down this stream, and we're trying to scoop them up.

Dr Bauer : In answer to your question too, we do acknowledge that there are definitely differences within families around their capacity, and there'll be some family members that definitely want to take that responsibility and others that do feel very helpless and frightened. It's how you get that middle ground and acknowledging that and acknowledging the difficulties, and also, with our local supports on the ground, acknowledging what an enormously difficult job it is for them to be at that front line in probably the sickest communities in Australia.

CHAIR: Just to jump in, I don't think I've got straight in my head where you have clinics. You were talking about the clinic in Halls Creek and said there's always somebody there. Is that one of your clinics?

Dr Bauer : Kimberley Mental Health & Drug Service works on the hub and spoke that you've heard a little bit about. Our major centre is in Broome; we have sites in Kununurra, Halls Creek, Fitzroy Crossing and Derby. But we do service the more remote regions of the Kimberley regularly, with our clinicians sort of based at each of these sites on outreach.

CHAIR: So you have clinicians based in those key centres you’ve just articulated?

Dr Bauer : On the ground.

CHAIR: In each of those locations?

Dr Bauer : Yes. So mental health, and drug and alcohol service, with a strong Aboriginal workforce.

CHAIR: Each of those clinics then has staff that have a clinic where people can go to for support?

Dr Bauer : Yes.

CHAIR: And you also then do outreach into the other communities such as Mulan, Ringer Stoke et cetera from Halls Creek, for example. Is that a correct understanding?

Dr Bauer : Yes, and Kutjungka, and in between visits we work very closely with primary care. So the Kimberley Aboriginal Medical Service clinic on the ground, for example, out at Balgo or Billiluna or Mulan has the capacity to videoconference or telephone support in between face-to-face visits. We also work pretty closely with the Yura Yungi Aboriginal Medical Service. It provides the Indigenous workers on the ground in those remote places, to provide mentorship and support.

CHAIR: Thank you. I wanted to make sure I had the layout in my head properly. And each of those clinics runs a 24/7 service?

Dr Bauer : The 24/7 service is telephone from Broome after hours, and in the other hubs it's the regional hospitals that will provide that service and ring us in Broome.

Senator O'NEILL: That's acute?

Dr Bauer : Yes.

CHAIR: So, if somebody's having a crisis after hours, which is when it's highly likely to happen, in Halls Creek, for example, the phone support would be at the local hospital?

Dr Bauer : There are a number of ways that support can be accessed.Certainly most people, if it's that degree of urgency, would go to the local hospital, and then they would most likely contact us if it's something they feel we could be of help for.

CHAIR: We heard about that—

Dr Tran : Sorry to interrupt. Therein lies one of the dilemmas. When a young person is distressed and, in the middle of the night, desperately seeks help, who are they going to call?

CHAIR: That was going to be my next question. They present at ED—and we've heard a number of accounts of people presenting at ED—but, when they get on the phone, who deals with that if they're in Halls Creek? That's what I'm trying to understand. Where does that call go? Does it go to Broome or does it go to somebody in Halls Creek?

Dr Bauer : If they've actually arrived at the regional hospital?

CHAIR: No. Say the family got on the phone seeking help. They haven't presented at ED, but they're on the phone for help.

Dr Bauer : Direct phone support to consumers and carers will be through Rurallink, which is a Western Australian funded after-hours service that can provide immediate linkages with us.

CHAIR: So they don't come into your teleservice here?

Dr Bauer : Not directly, but they can be involved once they've accessed the primary care or the hospital care. In most cases in a remote community, I guess the first point of contact would generally be the clinic, the nurse on call—

Senator O'NEILL: In their community?

Dr Bauer : In their community. The police often get involved as well. The police are often the conduit of care into mental health through bringing somebody into the emergency department.

CHAIR: What happens if something is escalated? What I'm trying to get to is: it's not quite a crisis yet, so we haven't gone to the ED, but the mum, dad, sister or brother is getting really concerned that something is escalating and they want to get help—the 'Let's see if we can de-escalate' type of approach. I'm still not clear. You said there was 24/7 help available, but the phone call that they make goes through to—what was the service?

Dr Bauer : Traditionally orientated Aboriginal people probably feel more comfortable with face-to-face contact rather than ringing somebody on the phone. In our experience, most of the contact would be through the primary care clinic or the regional hospital. But, if they did want to ring, it would go through to Rurallink.

Senator O'NEILL: Which is in Perth or somewhere?

Dr Bauer : Yes.

CHAIR: The clinic itself is not open 24/7. In remote communities, there's always a nurse on call.

Dr Tran : The mental health clinic isn't open 24/7. We don't have the staffing or resources to do that.

CHAIR: That's what I'm trying to understand.

Dr Tran : That would require the person to seek help at the clinic in the first place. As I think you mentioned, Senator O'Neill, in the first place people feel reluctant to even come to the mental health clinic. That's quite true. Again, it's a Western building, it's a white-fella institution, and why would someone go to the institution that is a product of the same system that has produced successive policies and practices that put that person in that dire situation in the first place? We're trying to remodel our service to change the way we do things and make our services accessible rather than make people come to the clinic and say, 'Be punitive. If they don't come, then it's three strikes and they're out.' That's not the way. We've got to step out of our comfort zone and go out with the permission of community, with the facilitation of strong local people to help make that happen so that we can use our expertise to enhance what's going on in the community rather than—

Senator O'NEILL: Do they need to be paid? Do the healing leaders in communities need to be identified and paid to do that work so that there is value attached to their work—continuity; capacity; plug them into support systems? Is that a systems response that we need to begin to consider?

Dr Tran : That's something that I can't answer on behalf of those people or those communities. However, my answer from my perspective would be yes. Anything less than that is tantamount to systemic institutionalised racism, by saying, 'This service is essential, yet we're not going to place the same socioeconomic value on that essential service.'

Senator O'NEILL: Very well put. So we've got elegant descriptions of the problems. I'd love to hear your thoughts about solutions and ways to get to solutions. Not to actually come up with a solution now, but what way is forward from here to solutions, from what you can see?

Dr Bauer : You've heard, I'm sure, about the complexity of the issues in the Kimberley and that there is not going to be one solution. Historically, it's been about white services coming in and trying to develop a solution.

Senator O'NEILL: So don't fund more mental health workers?

Dr Bauer : We'll get on to that, but certainly what we'd aim to do is to increase the community capacity. That example that you just gave about valuing local people in the community and supporting them to provide that service is a really important part of what we would like to prioritise as a service, with our partnerships. As I said before, we recognise that we are at the pointy end of the service; not many people are going to enter at our level. So what we have to do is try and increase the capacity and the competence of the many other providers—and there are many providers in the Kimberley—in the health and welfare sectors. Our aim is really to contribute to having a coordinated approach throughout the Kimberley.

There are some good examples of solutions. We do have the Kimberley Aboriginal Health Planning Forum and we have a very strong mental health subcommittee on that, which meets regularly, with a lot of expertise around the table, on developing shared programs with shared visions and really trying to enhance collaboration, to get people the best access and the most efficient use of resources.

For us, in our service, our priorities are really about strengthening our Aboriginal workforce. Currently about 22 per cent of our workforce is Aboriginal, and we really want to try and provide leadership opportunities and further enhancement of the workforce. As Duy has mentioned, I think that's where we find that local knowledge and that local expertise, and the trust that people have in them is exceedingly important for our service. We've prioritised our partnerships with the Aboriginal medical services across the region and getting right into the remote centres. We've prioritised working with GPs. We've prioritised making sure that clients that are sitting within our service in case management are getting all their health needs met—physical health needs as well. We have relied quite a lot on Commonwealth money as well as state money to try and enhance some of our outreach into the smaller hubs, provide partnerships with GPs and provide some other innovative services, such as making sure some of the young people in the region are getting proper assessments for autism and other cognitive disorders, like fetal alcohol syndrome. We acknowledge that there are certainly lots of challenges in providing services across such a remote region with such sociocultural economic disadvantage. There are challenges for our workforce in recruitment and retention. In smaller places, it's an ongoing issue. So supporting our workforce is important as well. Many of our workforce, particularly our local people, have been traumatised themselves. So you've got a traumatised workforce dealing with very traumatised populations.

So the short answer is we're looking on many fronts really. We realise that we're a small part of it, but it's about working together. You've heard a little bit about the suicide prevention trial. The Commonwealth funded one. As you know, we've got our state funded one and I guess our KPIs are somewhat similar, but it's around trying to align them, minimise duplication and really working with local communities. There will be communities that feel they haven't had a fair hearing, which I think Rob was trying to convey. I think we want most of the solutions to be grown from the ground up.

Senator O'NEILL: I'm keen to get your view on the suicide prevention trial, because it's been quite contentious.

Dr Bauer : The Commonwealth funded one?

Senator O'NEILL: Yes, the Commonwealth funded one. We've had very varied reviews here today.

Dr Bauer : I acknowledged the difficulties. I think it's very difficult on a four-year cycle to feel like there are really measurable outcomes, because, as Rob said, it does take a lot of community engagement and consultation before we can get somewhere. There have certainly been issues around the workforce, and I'm sure you've heard what Rob mentioned around the working group. We have good relationships with Kimberley Aboriginal Medical Services, and we're working really together. As I said, we're trying to minimise duplication. I think it's really hard to get something really concrete to say that yes that's worked at this point in time. It does seem as though it's been going a long time, but in the general scheme of things there are incredibly complex issues that have to be grown from the ground up.

Dr Tran : Just in response to some things that have been said, if mental health are given more resources then yes we'll be able to fish out more people who are drowning. Those kinds of things will work in practice at a small level. So if we can employ more Aboriginal mental health workers, if we can employ more doctors, if we can employ more nurses, then yes we'll be able to provide more essential services on the ground as well as do the networking and education that's necessary. However—

Senator PRATT: It doesn't change the social determinants of health, does it?

Dr Tran : That's it. So that's in practice. Then there's still that bigger principle. Somewhere like Halls Creek can be a bit of a microcosm of what needs to happen on a broader level. In Halls Creek we, as a service, are advised by the local Aboriginal owned organisations and by the community. We don't try to enforce our structures and our practices on the community. We get the feedback from the community first, and try to work within that. That needs to happen at a broader level. So at a community level, at a political level, there need to be that advisory coming from Aboriginal people to best direct the resources. That's got to be enshrined some way in the national psyche and enshrined within legislation or within something even bigger than legislation, and I think you know what I'm talking about. So that's about it.

Senator O'NEILL: It's a pretty big shift that we're after.

Dr Tran : Yes. It won't happen unless there is broader community buy-in from the non-Aboriginal population. But it also requires strong leadership and it requires someone to lead that conversation in a constructive way, to find a way to bring the whole country with us in what we're trying to do.

CHAIR: That's a very good point for us to finish on. Thank you. That was a powerful way to end

Dr Tran : Thanks for the opportunity.

CHAIR: Thank you very much for coming. We really appreciate it. It was really important for us to get your perspective. Thank you very much, and thank you for staying late. I apologise for running us over time, but we're just getting such valuable evidence that we just keep wanting to talk to people. That's the end of today's hearing. Thank you to all our witnesses. Thank you to our broadcast and to our secretariat. We'll adjourn and meet again in Darwin on Monday morning. Thank you.

Committee adjourned at 17:43