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Community Affairs References Committee
05/06/2018
Accessibility and quality of mental health services in rural and remote Australia

HAGON, Mrs Janice, Integrated Care Manager, Amity Health

HARRIS, Mr Christopher, General Manager, Community Engagement, Youth Focus

HEADLAM, Mr Benjamin, Manager, Great Southern Community Alcohol and Drugs Service, Palmerston Association Inc.

KALAF, Ms Fiona-Marie, Chief Executive Officer, Youth Focus

WENZEL, Dr Andrew, Manager, headspace Albany

WOOLLARD, Ms Alison, Mental Health Manager, Amity Health

[12:00]

CHAIR: I now invite representatives from Youth Focus, Amity Health and the Palmerston Association. Welcome. You have all been given information on parliamentary privilege and the protection of witnesses and evidence. Do you have anything to add to the capacity in which you appear?

Mr Harris : I am a psychologist.

Ms Woollard : I am a clinical psychologist.

Mrs Hagon : I am a registered nurse.

CHAIR: Thank you all for coming; we very much appreciate it. I'd like to invite whoever wants to make an opening statement to make an opening statement. After that we will ask you lots of questions.

Mr Headlam : On behalf of Palmerston, I want to thank the senators and the committee for providing us the opportunity to provide evidence today. Serving the community for almost 40 years, Palmerston Association is a leading and respected not-for-profit provider of alcohol and other drug services in Western Australia. We operate throughout the metropolitan area and in the Great Southern community from Albany, Denmark and Katanning. We also deliver residential support through the Palmerston Farm therapeutic community and the new therapeutic community at Brunswick Junction, which is also a regional centre with high need. We're funded through tendered contracts with the state and Commonwealth governments—in the latter case, through the Department of Health; the primary health networks; the Department of Social Services, through communities for children; and the Department of the Prime Minister and Cabinet, through the Indigenous Advancement Strategy.

We've been operating in Albany for over 20 years. Our core services include counselling for individuals, families and the community; centre-based outreach, individually and in groups; family support for those experiencing difficulties with a family member's drug use; specialist programs for families with multiple and complex needs; specialist support for people with co-occurring mental health and drug and alcohol issues; dedicated youth counselling services, including outreach counselling and education to groups in the community; and rehabilitation groups to prisoners in the Albany Regional Prison.

During the 2016-17 financial year as an organisation we provided support to close to 6,000 registered clients of all ages from as young as 13 to well over 60, and this was done either in the community or a residential setting. There has been an overall increase in demand of 13 per cent in the past two years. One of the largest single cohorts remains the 30 to 39 year old age bracket. Forty-two per cent of our clients are under 29 years of age. Across the organisation, 11 per cent of our clients are Aboriginal; however, in the Great Southern that figure is 30 per cent. Specifically in Katanning and the region around there in the central upper Great Southern, we see 50 per cent of our clients as Aboriginal. Patterns of drug use have shifted significantly in recent years. Historically, alcohol has been the primary drug of concern for Palmerston clients. However, in the 2016-17 aggregated data across the organisation, methamphetamine emerged as the primary drug of concern. In the Great Southern, we see a very similar picture, however cannabis has long featured heavily in the Great Southern.

The significant increase in presentations for methamphetamine complicates responses to co-occurring mental health issues. People experiencing long-term problems with methamphetamine use are at a significantly greater risk of developing mental health issues, particularly those with psychotic features. Given that there is an average of seven years between first use and first seeking help for methamphetamine, there is a lot of opportunity for damage. We continue to see a large number of clients seeking help with this drug and its impacts on their mental health. This is something that is likely to increase for some time. In 2017, 75 per cent of clients engaging with our service for the first time in the Great Southern self-reported current and ongoing mental health concerns. More concerningly, 52 per cent of our clients have had a diagnosis made by a mental health professional for a mental health issue.

It is well understood that AOD issues and mental health issues go hand in hand, each compounding the other and increasing the complexity of treatment and support. This needs to be understood by policymakers and funders, particularly as we know that many of our clients need long-term support: months, if not years, but not weeks. There is a cost to supporting people with complicated social issues in the regions. As a mental health clinician with close to 20 years experience delivering services in the regions in Australia, I can attest firsthand to the impact that isolation, both geographical and social, has on a person's willingness and ability to seek help.

With limited resources and ever-increasing pressure to deliver services more efficiently, both government and not-for-profit services face significant challenges in doing the thing that isolated people need most—that is, being there, which essentially means providing the help that is needed when it is needed and, importantly, where it is needed. While communication technology is a valuable tool in this respect, today's challenges with our power highlight some of the inevitable challenges to reliance on technology. These are only amplified in high stress situations. Those needing help are often expected to travel—we have heard this today—sometimes long distances to get the help they need. In many cases this requires them to overcome barriers that are often part of their mental health issue. They also need to understand and navigate a system that is fragmented, often arbitrarily separated into silos that focus on specific issues of a person. The well-worn concept of 'no wrong door' has not created the ease of access to services that was intended. Services need to move away from the expectation that their clients must come to them. For people experiencing mental health problems, those who feel isolated and alone, those contemplating suicide, the easier it is to think it is too hard to get help, the less likely they are to get it.

Whilst governments acknowledge the challenges of regional service delivery, all too often there are systemic barriers, particularly in the tender process, where not enough weight is given to the reality of travel and staffing costs, and other factors that impact on accessibility. Palmerston is proud of its response to the issue of access in remote areas, particularly in the Great Southern. This includes culturally secure programs for Aboriginal people that use kinship links to access people in need who might not otherwise be identified. We also use an eclectic array of models and approaches, like the Red Dust Healing model, which help people overcome the stigma and past trauma often associated with mental health and AOD support. We deliver services in partnership with other organisations—for example, Amity Health here today—which improve community presence, the limited resources and extremely complex needs of people in community with mental health, AOD and other social needs. Greater capacity, stronger collaboration and better tendering models are needed simply to make a dent in the issue. Competitive tendering continues to drive competitive service delivery, and this stands as an ongoing barrier to truly collaborative service delivery and perpetuates the silos that hinder the ability to reach and provide wraparound services to isolated people.

Ms Kalaf : Thank you for this inquiry and for taking the time to hear the views of Youth Focus and our colleagues. Youth Focus is an independent organisation with a mission to support young people aged 12 to 25 at risk of anxiety, depression, self-harm or suicide. We deliver primary mental health services and education programs to not only reduce symptoms associated with suicide, depression, anxiety and self-harm but also build long-term mental wellbeing and help young people reach their full potential. In addition to our frontline counselling services we engage with communities to educate and build awareness about youth mental health issues and suicide prevention. As part of this engagement we deliver education programs in schools and communities across Western Australia. Youth Focus is based in Burswood and has offices in Joondalup, Rockingham, Bunbury and Albany. Additionally, Youth Focus is the lead agency for three headspace centres in WA—Albany, Geraldton and Midland—as well as the headspace Youth Early Psychosis Program in Midland.

The 2017 Mission Australia Youth Survey revealed that over a third of young people—36.9 per cent—in regional areas did not feel positive about their future, with the greatest concerns being mental health, alcohol and other drug use, equity and discrimination. This high rate of lack of confidence in the future has a detrimental impact on the country's social development and protection. The question going forward is how we ensure support services are available to address these concerns. The same survey also reported that the people these young people turn to are friends at 82 per cent, parents at 77 per cent, and relatives at 64 per cent. Almost half, 47 per cent, sought support from the internet, and only 16 per cent indicated they would use online counselling. This would suggest an importance on ensuring the young person's second circle has the confidence, skills and willingness to support the young person at the earliest opportunity. It also suggests that, although digital media have a place, young people see them as having only a partial role in service delivery.

Data further indicates that, if a person lives in regional or remote Australia, they are more likely to have a chronic mental health condition, at 19 per cent, when compared to a person living in a major city, at 17 per cent. With 75 per cent of mental health conditions having an onset prior to the age of 25 years, a logical step forward is to provide increased services much earlier to young people living in these areas. Western Australia's suicide rate has been consistently higher than the national average since 2006. Evidence suggests that the more remote and the further from the capital a person is, the greater the risk of completed suicide, such as in the Kimberley region, where suicide rates are 2½ times the state average and more than 3½ times the national average. There is a 1.7 times higher rate of suicide in remote and very remote areas compared to major cities. With reference to youth, 2017 figures in the latest WA Ombudsman's report shows that 42 per cent of all sudden deaths of 13- to 17-year-olds between 2009 and 2017 were a result of suicide, much more than car crashes, at 29 per cent, illness or medical conditions, or any other accidents. Last financial year there were 19 suicides of teenagers aged 13 to 17, compared to 13 in the 2013 to 2016 period and nine in the 2009 to 2010 period.

We are concerned about the lower rate at which young people in rural and remote Western Australia access mental health services—and, in turn, the high suicide rate of young people in rural and remote Australia is of considerable concern—and we believe that a number of issues contribute to this lower rate, including gaps in services and funding, geographical issues, and social and cultural issues. Additionally, we see challenges in regard to the mental health workforce and the economics of service delivery. On a positive note, we see some opportunity to deploy technology based service delivery solutions. By way of context, in the year to 30 June 2017 Youth Focus provided counselling services to 2,874 young people through its Youth Focus and headspace centres. In headspace Albany the centre provided services to 532 young people in the year to 30 June 2017, which, according to ABS data, represents almost 10 per cent of the young people of Albany.

Mr Harris : Going a little bit broader, in terms of making an impact in terms of mental health and for young people, we have to acknowledge that we cannot talk about health without talking about mental health. We need to change how we approach this. For instance, everything that you're going through now—writing, listening to me—actually goes through your brain. Yet we don't encourage young people or others to think in those terms. If you want to lose weight, your brain has to do that. We need to shift this idea that mental health is somehow bolted on the side.

A male year 12 student from One Arm Point Remote Community School up in our north-west is believed to have died by suicide on Friday, 11 May. We get these reports every week. What we need to start having conversations about is: did this young man have access to preventative services, early intervention services, and what supports will be available for that community if we are truly committed to providing our young people and their families with the support that they need?

You will already know that mental illness is the third-greatest burden of disease within our country in terms of lives lost and economic cost. By 2030 it will be the leading burden of disease. We in this room—the Commonwealth, the state and communities—are standing at a precipice. We have to make decisions to abridge this and to change that trajectory; otherwise we'll sit here in 10 years and wonder what we could have done.

For 17 years I was head of services at our local children's hospital eating disorders team. I moved to Youth Focus, a not-for-profit agency, because, after 17 years, I realised that the money, the resources, the services, were not going to prevention and early intervention and there was not optimal service distribution. In fact, I was probably one of those people who were suggesting that, at tier 4 or tier 3, we could change this—and I've realised that it isn't at that particular point. We have to work much earlier and work with communities.

There is certainly a crisis of confidence. Young people's deteriorating level of confidence, however, is not in themselves. Their deteriorating level of confidence is in those around them—in their parents, their families, their teachers, their coaches, their politicians. When they say, 'I'm struggling and I'm doing it hard,' our young people don't feel confident that those people know what to say or what to do at the earliest opportunity.

Young people in regional and remote Australia have a right to create a livelihood for themselves. Australia was built on the economy generated within regional and remote areas. Our economic growth is dependent upon the social development and protection of these young people. To achieve this, young people have a right to decent work, education, health, gender equality and participation in their own future. At this stage, mental ill health is a barrier to them accessing this. We have to remove mental health as a barrier to young people being able to create a livelihood for themselves. That includes workplaces. It includes acknowledging that getting a good job is good for mental health, that seeing education through is good for your mental health, that participating as a volunteer is good for mental health. As such, we need to look at innovative funding models that are less siloed and that recognise that, through education, employment and the health sector, we can improve the wellbeing of young people and increase the likelihood of creating a livelihood—thereby with a goal, not only in terms of reducing the burden of disease but also achieving our current national, Commonwealth initiative of endeavouring to reduce suicide by 50 per cent in the next decade. Thank you.

Dr Wenzel : As Ms Kalaf has touched on, headspace Albany is a project through the lead agency Youth Focus, but we are providing services to young people through the National Youth Mental Health Foundation. We're one of the first 10 headspace centres established in Australia and the first one in Western Australia. Over the 10 years that we've now been working with young people in a collaborative wraparound service model, we've seen significant growth in awareness of mental health issues within young people and significant acknowledgement that getting help early is a significant factor in improving mental health outcomes.

As Ms Kalaf mentioned, we saw approximately 10 per cent of the 12-to-25-year-old population of Albany last year, and that's a growth of almost double in the last three financial years, despite no increase in funding during that period—and headspace services are predominantly federally funded through the Department of Health. So the challenge for us has really been about more efficient and more cost-effective service delivery for young people—acknowledging very much, though, that, in doing that, the model in which we're able to deliver services does have inherent gaps. The largest gap that we see down here is the gap between primary mental health services that we deliver, where young people can and do walk in and access help and ask for help, and those services that are state funded tertiary services. I think that, because of the flexibility and person centred approach of the majority of not-for-profit non-government services, we often react in a way that is perhaps more person centred than state services, where boundaries are rigidly defined and adhered to in terms of entrance criteria and admission criteria. So what that has meant for us is expanding services beyond what has traditionally been the remit of headspace services to fill a gap for young people, particularly for a group of young people who are perhaps frequent contactors of the service, with chronic suicidal ideation, where a brief primary Medicare funded counselling model of up to 10 sessions per calendar year just isn't sufficient.

This has also come at a time when we've shifted the funding model for headspace centres from headspace national as the conduit of that funding through to Primary Health Networks. This has been accompanied by not just a lack of increase in funding but quite a deal of uncertainty around funding, such that we've been on annual contracts for the last three years for our core services, which fund about 30 to 35 per cent of the services delivered at a headspace centre. The remainder are funded through accessing Medicare funding, through in-kind service delivery, through agencies like Palmerston and Amity Health here, and through accessing other tender opportunities, donations and those sorts of things. Still we sit here now without a contract to deliver services from 1 July. For services where there are already difficulties in attracting and recruiting mental health professionals, that contract uncertainty does add to the considerations around whether a career in a not-for-profit non-government mental health service is a viable and attractive one compared to state government services, where the salaries generally tend to be higher, as well as job certainty. It also means difficulty in planning and implementing strategic and well-considered mental health services beyond just a hand-to-mouth approach of, 'Let's see what we can do in the next little while.'

While the data supports the view that the majority of people accessing primary mental health services are able to receive help that they deem sufficient in a 10-occasion-of-service model, for those that aren't we're effectively seeing a population where that instability in terms of ongoing service planning and service delivery means that the more disadvantaged young people, with a more severe impact from their mental health issues, are being further disadvantaged through that lack of certainty around service provision.

CHAIR: Thank you. Ms Woollard?

Ms Woollard : I'd just like to introduce Amity Health and the scope of our service. We're a not-for-profit agency, and we provide mental health services at a tier 2 level throughout the Wheatbelt and the Great Southern. We've probably got 13 staff, which consist of social workers, nurses and mental-health-trained OTs. Our funding comes through WAPHA, and since 1 July last year we've had 1,190 people access our services. So we provide services throughout the age range. I think our oldest client has been about 85.

To reiterate what Andrew has just said, our funding hasn't been officially confirmed to continue. As at this point, we have till 30 June, and that's when we finish unless we get officially told that we've got some funding for next year.

CHAIR: I'm sorry to interrupt. Can I ask both of you: I presume there are discussions going on?

Ms Woollard : Yes, there are discussions going on, and unofficially we've been told that we will have funding, but officially we haven't had that confirmed.

CHAIR: Sorry, I interrupted. Did you have anything else to add?

Ms Woollard : Basically, I just wanted to give a broad outline.

CHAIR: Can I just follow that through, and then I'll hand over to Senator Hinch, who will ask some questions. What is the hold-up? What are you being told is the hold-up? Government is supposed to have recognised now for some time that these delays in contracts are a major problem for all the reasons you've just articulated—the uncertainty, losing staff et cetera—which are particularly important for rural, regional and remote areas. What has been the feedback about why it's taking so long?

Mr Headlam : I think we're all essentially—

CHAIR: You're all in the same boat?

Ms Woollard : Yes.

CHAIR: Okay. So what have you all been told?

Mr Headlam : Essentially, with the new contracting commissioning model, Primary Health Networks, in the last few years there has been a bedding down of that process. Essentially, that's adding an extra step in the contracting process with the Department of Health, so they cannot issue their contracts to their service providers until theirs are solidified. I believe that that has been the primary driving delay.

Senator BROCKMAN: Effectively, is this a bedding down of a new process? Assuming everything works out the way you would want it to this time, is, then, the process going forward a better process?

Dr Wenzel : One would hope so, but we've now been on three years of single-year contracts when, prior to that, we were on a three-year-plus-two-year contract model.

CHAIR: So it's not just bedding down a new process.

Dr Wenzel : It partly is—

CHAIR: It's three years.

Dr Wenzel : but it's taking a long time to bed down, and we're led to believe that that process still isn't stable and has been a part of that primary mental health—

Senator PRATT: The government changes them quickly enough anyway, even though—

Mr Headlam : Within that three-year period, being the Primary Health Network's first contracting period, there has been a transition process whereby a number of the contracts that were previously delivered by the Department of Health have transitioned over on short-term contracts to the end of that contracting period. So it is hoped that, now that that transition has completed, with the upcoming contract period, that will be solidified into a single period.

Senator BROCKMAN: You've got a 1 July date. Are you expecting another year, or are you expecting another two years or three years?

Ms Kalaf : It depends on the nature of the existing contracts. Youth Focus, as I said, is the lead agency for three headspace centres. We're anticipating another one-year contract and then, after that one year—hopefully, early in the new calendar year—we're anticipating a negotiation period where I think most of the headspace contracts will be up for renewal and offered over a three-year period. That ideally should give us more certainty.

Senator BROCKMAN: Is that uniform?

Mrs Hagon : No.

Ms Kalaf : It is contract dependent. Youth Focus also has contracts with the WAPHA outside of headspace, and they have different contracting periods and contracting terms.

CHAIR: Ms Woollard, did you want to add something.

Ms Woollard : For Amity, it's possibly two years funding.

CHAIR: You're negotiating two-year funding?

Ms Woollard : Yes.

Mr Headlam : As an organisation, with our nine contracts that transitioned from the Department of Health to the primary health networks, we are expecting that all but one or two of those will be negotiated at a three-year funding term.

Senator PRATT: What's ideal—five years?

Mr Headlam : Five years or 10 years.

Dr Wenzel : We are now starting to see jurisdictions overseas with 10-year contracts. That allows a generation of planning and service delivery with stability and confidence.

CHAIR: One good thing about Stronger Futures, which is the Northern Territory intervention program, was the commitment to NGOs for 10-year contracts, which was then unwound.

Ms Kalaf : Particularly for workforce planning—

Mr Headlam : Absolutely.

Ms Kalaf : enabling somebody to make a commitment to move to a rural or remote location and stay there and make that their community for a long period of time.

Mr Headlam : If we're talking about accessibility, one of the keys—and we've heard it mentioned by previous witnesses—to driving accessibility in the remote areas is all about relationships. Within these programs, it takes time to develop the trust of a community, and that trust is more and more difficult to develop when the community witnesses programs coming into the community for a period of time and then being defunded, and then it becomes much more challenging to establish new relationships.

Senator HINCH: Mr Harris, you mentioned the brain and it leads me to a question to Mr Headlam. Was it Great Southern that also looks after drug and alcohol rehabilitation for prisoners? Is that right?

Mr Harris : We do. We started that contract on 1 May this year. It's a new program. It's a manualised 100-hour rehabilitation program for up to 12 participants in a single group. Two groups run concurrently for 100 hours.

Senator HINCH: Not many people can say this, but the last time I was in jail—

CHAIR: He takes great pride in saying that!

Senator HINCH: I do like saying that! The ice epidemic is also very strong in our prisons in Victoria.

Mr Headlam : Absolutely.

Senator HINCH: I talked to corrections officers who said to me, 'We're not guards anymore. We're looking after people whose brains are fried.' That is the expression they used. Some had been in, got out and went back in and didn't know where they were or where they had been. Their brain was physically gone. Do you find that with people coming out of jail?

Mr Headlam : To a large extent, certainly at our therapeutic communities. There is a farm at Wellard, south of Perth. We have a large proportion of people coming directly out of prisons to that community. We're the only service that accepts people directly from prison into the therapeutic community. We have a large proportion. I think that at one point nearly 20 per cent of our 40 beds were taken up by people direct from prison. The cognitive impacts that long-term ice use have are not like the majority of other drugs that we witness. It can take 18 months from last use to recovery for the brain to return to premorbid function, and even then it's to a lesser degree. We really are seeing significant impacts on cognitive function as well as mental health.

Senator HINCH: I think the word is 'synapse'. They burn, so the next time they take it, they won't get the same hit, so they take more and it causes more physical and permanent damage to the brain. Is that right?

Mr Harris : As Ben indicated, we probably don't fully appreciate the impact that a drug such as ice has. In terms of recovery process, it's about whether a person can recover, because the damage does have long-lasting and potentially permanent impact. Like I was saying, when you look at the impact and being able to get into work or education or being able to parent et cetera, the shrapnel of something like ice is far-reaching and phenomenal, in terms of a community's functioning ability.

Senator HINCH: I know neurosurgeons in Melbourne are very worried about it, apart from the fact they're getting nine grey alerts in hospitals and emergency rooms. The fact is there is such permanent damage.

Senator BROCKMAN: On headspace, you both mentioned the figures of 10 or 12 per cent of young people in Great Southern or Albany—

Dr Wenzel : The figure equates to 10 per cent of the 12-to-25-year-old population of Albany.

Senator BROCKMAN: When you say you saw 10 or 12 per cent, what do you actually mean when you say 'saw'? Are they presenting or are they just dropping in to say, 'What happens here?'

Dr Wenzel : They are registered as clients so they came in requesting assistance with a mental health issue that may or may not be a diagnosable mental illness, but the headspace model is not just responding to illness but also acting early to provide services, education to young people, their families, and mental health skills to hopefully prevent anxiety and depression symptoms escalating to the point of illness. We were established with the brief of trying to prevent the onset of mental health issues as well as treat mental health issues. Down the track, we hope that that will also have a knock-on effect in the reduction of mental health instances of illness for adults as well.

Senator BROCKMAN: I started today quoting some statistics on the Great Southern Region, particularly in relation to young males, which are pretty dreadful to be perfectly honest. We got some evidence to say they don't think there has been any great change in that, no deterioration but no particular improvement. From any of the service providers, is there any sense of why that figure is particularly bad for the Great Southern? Because you certainly wouldn't put in the category of being particularly remote. I don't think most of us, as Western Australians, we would even think of the Great Southern as being remote. We think of it as much more regional and relatively close to services such as the ones you provide. Is there any sense of why that number is as bad as it is and whether we are making any inroads?

Mr Headlam : It would be interesting to have a look at how over represented Aboriginal young males are in those figures. The Great Southern Region is a very town centric region, particularly in service delivery. We are not often seen in the regional breakdown of Western Australia as an area of high need. But what we do have is a highly fractured Aboriginal community that have experienced generations and generations of trauma and have not had—I would suggest when we compare with regions in the Kimberley, in the Pilbara or in more remote regions—the connection with their culture that the Noongar people in the Great Southern have had. So particularly with young males, there is a strong sense of being disenfranchised, of not having vocation, of hopelessness. Certainly we see a massive over representation for drug and alcohol issues in young Aboriginal males, and I would expect that the data would show that the same over representation occurs with youth suicide.

Mr Harris : I co-chair with Professor Patrick McGorry the national steering group on the young men's project which is linked to Youth Focus. That was a national initiative having a look at how we do we support young men to engage services much earlier. A couple of things have come out of that particular group. One is that mental health related conditions and suicide may be linked closely to a sense not feeling valued or an anxiety around a fear of failure and not being good enough rather than depression per se. The other aspect we found with young men was that the suggestion that help is needed triggers kind of a biological response which they will defend against because they don't want to be seen as what we call the 'runt of the litter'. We have to change how we approach this with young men so we are moving towards a strength base. Would you like to feel closer to your partner? Would you like to laugh more when you are with your kids? Would you like to feel more valued in your community? Then we introduce mental health services. I am not sure specifically for the Great Southern but I do know going forward that we now have some insight about how we engage young men differently perhaps than what we previously attempted to.

Dr Wenzel : For the Great Southern Region particularly, the demographic data suggests that Albany and the Great Southern is a region that young people leave when they hit 18. We are over represented in school age in state and national demographics but we know that in the 18- to 30-year-old cohort, we are under represented in that age group compared to state and national demographic data. Part of the reason for that is that young people have been leaving Albany for study or for work and the Great Southern has been an area without an economic driver at the time of the resources boom, and it's reasonable to hypothesise that those young people who stay perhaps may be skewed towards a group who might be less skilled, less confident, less together, for want of a better word, and more isolated—features that make them more at risk of mental health conditions. That may explain why data is skewed towards that population or towards a higher rate of mental health issues and suicide in the Great Southern than other areas. That's just a hypothesis.

At headspace we have been deliberately targeting young men, through marketing strategies, through the way we deliver services and through changing the mode of service delivery to provide some after-hours services so that young males who are working are able to access services. We still see an under-representation of males—around 65 per cent females accessing the services, 35 per cent males. Interestingly, when we break that group down, the group of young men that don't come are the group right where we start to see the onset of mental health issues—the 15- to 17-year-old cohort. They are between an age where they're under the influence of their parents who can help them access services and come in for the first time, and the age where perhaps they have a greater degree of insight into what's going on for them. We do see those numbers picking up in the twenties for young men. That 15- to 17-year-old cohort just seem to find themselves perhaps a little bit bulletproof. That's also supported by what we know about the way brains develop. Young men's' brains develop a little bit slower than young women's brains do. That's particularly in the centre of the brain that's in charge of reasoning and planning and big picture sort of information.

Senator BROCKMAN: So bulletproof but at the same time starting to disengage—back to what you said, Mr Harris—from both education and, potentially, the workforce.

Mr Harris : Certainly. Yes. I do think it leads on to the role of communities, in terms of mental health strategies, and how we empower communities. Sometimes I think it's how we engage already existing strong community groups and give them the skills to recognise this much earlier, a little bit like we do within physical health. Certainly for us and at Youth Focus, recognising that symptom reduction—and certainly tier 4, tier 3 services—but we have to kind of move beyond that, and it's about a sense of purpose, a sense of meaning, a sense of wellbeing. We think that rests within communities. We actually have a degree of optimism around that. If you can engage communities—like Keep Australia Beautiful, Keeping Australia Alive—and around towns that have mental health strategies and approaches, I do think there's an opportunity to empower communities more going forward. I think that might be a point where we engage young people much earlier and men much earlier.

Senator BROCKMAN: Thank you.

CHAIR: Thank you. Senator Pratt.

Senator PRATT: In terms of the 10 per cent that are accessing local headspace services, on one hand that looks like there's a big problem in the community, but it's also a sign of success that access to the service is destigmatised to the extent that people are prepared to go.

Dr Wenzel : Yes.

Senator PRATT: What has been the key to that?

Dr Wenzel : I think stability and consistency, as well as building up trust in terms of the quality of services and communication with other services, whether that's GPs, whether that's school psychologists and services like that. In addition to the one-on-one services, we do have a significant focus on mental wellness promotion and increasing community education. We have someone specifically employed for that region. So we are going out and delivering talks to schools. So we now have a generation of young people who have grown up having heard about headspace and that's starting to be reflected in the numbers. If we break down that number of 530-odd that accessed the service last year, almost 200 of those were people who had access to headspace services before. So we are now starting to see young people return in the next stage of their live. We may have helped them as young high school students and now they are young adults, perhaps even young parents, and they are coming in to access services.

Senator PRATT: If they're going through their life course and people still need support, where are you kicking them on to, once they're not young anymore?

Dr Wenzel : That's another gap in services. We're referring young people to Amity Health through primary mental health services, back to their general practitioners, and through other agencies, like Relationships Australia. The majority of the services and supports that we provide are episodic in nature, so we will have tied up that episode of care rather than necessarily needing to hand someone over to continue to receive care. But those that we do are the agencies that we tend to plan with.

Senator PRATT: In terms of your client base whose experiences through headspace have left them in a better position to manage their own mental health and identify how to manage depression and anxiety and have improved their skills, what proportion of your clients do you think have understood that and got it and are able to move on with their lives, versus those who need more ongoing support?

Dr Wenzel : I wish we knew the answer to that. That was the great hope of headspace when it was established. The concept of early intervention and prevention in terms of generational affected mental health is still a little bit new. I think the research is probably not there yet in terms of that effect across a cohort of a generation. If we look at what we know about mental health services anyway, a third of mental health issues will go on to become complex and chronic. We're not at a point yet where we've seen what that might look like. We know that young people who are being asked information about whether they felt they learnt more about their mental health issues and whether they were satisfied with the support they got—that sits somewhere be 85 and 90 per cent of young people accessing headspace Albany, and that's pretty consistent with headspace data across Australia.

Senator PRATT: Okay. Thank you.

Senator HINCH: I have just one quick question. Mrs Hagon, you said you were a nurse. Why are you here? What would you like to say?

Mrs Hagon : I've travelled throughout Australia working as a registered nurse. I worked a lot in the Northern Territory and there were a lot of mental health issues out there. I made a move to Mount Isa where I worked for headspace as a manager out there. I moved to Albany because this job was available. I think coming here has shown me that there are gaps all over Australia, not just in WA. What is quite consistent in every area I've worked is the stigma around mental health and people not accessing services. As a mental health clinician moving to Albany, I'm still trying to find out what other services are available. I've found it difficult, and I'm thinking, if I can't find my way around it all, maybe they're having the same problem and they don't know what's available. I travel to some of the other regional areas around Albany; it might be a couple of hours going out towards Gnowangerup and Tambellup. I find out there that they have a great need from talking to the GPs for access to mental health services. But I found out there, from talking to the GPs, that they have a great need for access to mental health services, but because the local Aboriginal community still identify these small towns as places where everybody knows everybody's business, they won't access the services. Even the locals in one of those towns will go to another town to access GP services. Mental health services are a no-go area sometimes for a lot of these clients. So, yes, I've come across so many situations where they might come for one visit but then they're too scared of what's going on around the community that they would identify that they have a problem.

CHAIR: I want to follow up from where you've just left off. A lot of those communities don't have any permanent services, so there are people coming in. Will people travel from another town to access the service when you're in—say, people from Gnowangerup would go to Katanning. Will they do that?

Mrs Hagon : Well, they will, but it depends as well, because I know that they don't want the local GP service but they will go to Katanning to visit a GP out there. Maybe if those mental health services were provided outside of those towns they might travel. I don't know how that would look, really.

Mr Headlam : There also comes the question of means. Towns like Gnowangerup and Tambellup are reasonably remote. The means to travel from one of those towns to Katanning to access services for people who are significantly disadvantaged—and let's face it, we are talking about that demographic; this is the demographic most in need of mental health services—they don't have the means to get there.

CHAIR: We've already talked about how digital is not necessarily the way to go, and in particular again the group we're talking about may not have access to reliable digital services. They don't want to visit services when they come into town, for the reasons you've just discussed. Where do we go to from here?

Ms Kalaf : I think there's a range of factors that can go into it—so I think a combination. The fundamental difference between a rural community, say, and a metropolitan community is the availability of choice. In a metropolitan community, if a young person at school doesn't want to see their school psychologist—because within that community they feel that there's potentially a lack of confidentiality—then it's easier for them to access a service but still close to home.

CHAIR: [inaudible]

Ms Kalaf : That's right. In my opening remarks I said that technology solutions aren't necessarily the only way. That said, at Youth Focus, through a contract with WAPHA, we've recently opened up teleweb counselling services, which provides a much more cost-effective way for us to provide essentially an in-reach service—that combination of in-reach, outreach. And we still use teleweb counselling as a face-to-face service, even though it's delivered through a technology medium rather than in person. As I said before, fundamentally the issue in rural and remote areas is the lack of choice.

But backing that up a bit and zooming out to what Chris said earlier, it's also about that very early prevention rather than getting to the point of early intervention or indeed intervention. And that is around giving communities a resilience—ensuring that within communities we're doing what we can to reduce stigma, to make it okay for someone to seek help, to help the communities themselves more resilient, more able to support each other. That may well be not just through schools. Often schools are the biggest community within a community, but it could also be sporting groups and other groups within smaller regional areas. It's about skilling those groups up as well. Chris, I'm not sure whether you want to add to that in terms of community strength.

Mr Harris : Recently there were bushfires here. We see what communities are capable of in Australia, in remote and rural communities often when facing tragedies. Strangely enough, that gives me a strong sense of hope in a community's ability to come together. I think it's just how we frame it, how we talk about it, how we present it to communities. As we were saying, I think communities can come together—again, not with being the specialists, but the same with physical health: if somebody's down, how do we come together and support that person? And we do it so well in so many other areas. So, I think it's just how we talk about mental health like we talk about other aspects of our communities.

Dr Wenzel : But I think it also goes to what Dr Rock was saying earlier, that there are responses available but the range of responses isn't the same. Qualified health practitioners may be limited in what choice is available to them. And we know that provision of mental health treatments is imprecise in that we don't have the imaging or the investigation techniques to know that this medication will solve depression for all people and a person may actually be seeking a talking treatment.

Mr Headlam : To speak directly to your question about why they're not seeing people in their community when services come, I think there are a few factors, and one that we haven't really addressed in great detail is the stigma of mental health issues, particularly in a small community. We're talking about hundreds of people. It's not a far cry to know the business of everybody in the community.

Senator HINCH: Yes, that's the main driving point you were making.

Mr Headlam : Exactly, yes. And really I think the way through that is to think about how we're actually delivering those services, how we market and promote our services, because when we say we're coming in to deliver a mental health service or treatment for mental health issues, the moment you're seen accessing that service you are immediately identified within that community as a crazy person. Really, that's the feeling that an individual will be feeling when accessing that service. So I think it needs to be a little bit more holistic, a little bit more broadly driven. We take a similar approach to engaging with those communities for alcohol and other drug services and, in the majority of groups that we run in Gnowangerup and Tambellup specifically, attendees are unlikely to identify as a group about alcohol and drugs.

CHAIR: I've run us over time, but we started late. Apologies for finishing late. Thank you all for your evidence today. It's extremely helpful for us. So, thank you.

Proceedings suspended from 12 : 57 to 13 : 45