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Dr J J Brownscombe

14 August 2008

To the Northern Territory Emergency Response (NTER) Review

Re: Submission relating to the Drug and Alcohol Response component of the NTER (Measure 5.3)

Please accept this submission to your review.

I have been employed as the NTER Alcohol and Other Drugs (AOD) Clinical Director since February 4, 2008. My position is funded by the Office for Aboriginal and Torres Strait Islander Health (OATSIH) who auspice my employer, the NT Department of Health and Families (NT DHF). I report to a Working Group which comprises OATSIH (NT and Canberra), NT DHF and AMSANT (the Aboriginal Medical Services Alliance of the Northern Territory – the umbrella organisation for independent Aboriginal-run health services within the NT).

The role of NTER AOD Clinical Director has been to provide clinical and systems support around AOD initiatives within the AOD and broader health sector funded by NTER. (In 2007/08, $11.4 million was allocated for this purpose.) These include workforce expansion, capacity building within existing AOD and health services, and training. My role has extended to include strategic advice and development to the broader NT AOD sector, OATSIH, NT DHF, AMSANT and several independent Aboriginal Medical Services (AMSs). I have had no involvement with legislative changes around alcohol or any other aspect of NTER other than developments within the AOD treatment sector.

My professional background is as a medical doctor and specialist public health physician with an interest in alcohol and other drugs (AOD), primary health care (PHC) and community development. I have worked in both AOD and remote PHC in the NT.

I should state at the outset that I entered into this role with some moral misgivings regarding NTER: namely the lack of consultation with Aboriginal people around its conception and implementation, and the incompletely explored punitive aspect to some initiatives. When the NTER began I was working as a District Medical Officer (DMO) and was frustrated by the Australian Government’s failure to recognise and work with existing primary health care service providers. However, when I was asked to take on this role, I recalled the immense potential I once saw in the NT AOD sector, if only the political will and resources were available to develop it. Suddenly they were and I felt obligated to assist in this. I think one of the major benefits to flow from NTER has been to raise awareness around and provide resources to address some key health and social issues. I know that many good people from very different walks of life have worked hard and in good faith to maximise the positive impact of NTER initiatives on the ground and I feel privileged to have been part of this process.

Please note that the views expressed in this submission are those of the NTER AOD Clinical Director and should not be taken to represent those of the Department of Health and Ageing, NT DHF, AMSANT or any related agencies. Please note however that this submission was circulated to a range of key stakeholders for feedback, and amended, prior to being lodged.

I was fortunate to meet two of the evaluation team, Marcia Ella Duncan and Bill Gray, at the Garma festival in East Arnhem, on Friday 8 August. I thank them for our discussion and their guidance and encouragement with this submission.

This submission contains 3 main parts, relating solely to NTER Measure 5.3: Improving Child and Family Health – Drug and Alcohol Response. These are as follows:

Finally, after this main discussion, I make some comments relating to the warning signs outside communities, welfare quarantining and the phenomenon of labelling. These topics are outside my professional field, hence I make them as a member of the general public, albeit one who has lived and worked with Aboriginal people before and during NTER.

Background and Summary

The vast majority of NTER AOD initiatives have been in the form of additional funding for pre-existing organisations to expand their service capacity and scope. These organisations include Aboriginal Medical Services (AMSs), other non-government organisations (NGOs) including residential rehabilitation services and NT DHF (particularly NT hospitals). These organisations generally have sound track records and pre-existing relationships with OATSIH. The need for such additional services had usually been recognised by a range of groups and for a significant amount of time prior to NTER. For this reason, they appeared to be quickly accepted amongst mainstream services, and to attract relatively little controversy.

The main NTER AOD initiatives are classified as follows:

A major achievement amongst these has been the establishment of functioning AOD workforces within primary health care (referred to as AOD PHC services) – a new approach to service provision. Residential treatment services received funding for staff and operational costs to allow them to increase their bed capacity. Promising developments have occurred in the training arena, notably the introduction of narrative therapy approaches to a wider NT audience, and capacity building in primary healthcare around AOD knowledge and skills. Hospital-based management of withdrawal has received a boost, though progress has been slower than hoped.

Whilst I will address all NTER AOD initiatives, I will provide more detail around those with which I have been more directly involved. Particularly, my involvement with community education projects has been limited. Similarly, agreements around capacity building within residential treatment facilities largely took place prior to my appointment.

The NTER AOD initiatives funded by OATSIH are being separately evaluated and findings from this evaluation will be due in June 2009.

A progress report on NTER AOD initiatives, entitled NTER AOD Clinical Director’s Interim Report, is attached to this submission.

Response to NTER Review Board’s nine questions:

1. What is working?

There has been a successful pilot of Alcohol and Drug services within primary health care (AOD PHC services), mainly within Aboriginal Medical Services (AMSs). These do not provide complete coverage across the NT, rather have done some useful work in selected regions and groups. Nor can they yet be considered sustainable in the long term. I believe it is important to maintain these projects because of the goodwill and hope that has been invested in them. In the past, merely establishing such services had proven difficult because of resource constraints, but also logistical and governance challenges around having specialist services within a generalist health service framework. These services employ around ten Aboriginal people, four of whom have commenced formal training in the AOD field.

The NTER AOD initiatives in NT hospitals, namely the funded detox beds and AOD staff, have worked well when they have been in place. They have demonstrated that NT hospitals have the capacity to provide good management of alcohol and drug-related presentations and alcohol withdrawal. However, the impact of this initiative has been less than it could have been, for reasons discussed in the next section, below.

Education and training initiatives funded by NTER have helped raise knowledge and skills in the health sector and beyond. Narrative therapy workshops were run by the internationally recognised Dulwich centre, based in Adelaide. Narrative therapy approaches promote healing through storytelling and sharing. They seek resilience characteristics in people. They help overcome some of the problems associated with conventional therapeutic techniques, such as disempowerment associated with a hierarchical relationship between therapist and client. They seem well suited to Aboriginal people. The enthusiastic response to these workshops indicates a thirst for alternative therapeutic approaches amongst people in the NT.

Primary healthcare services have benefited from in-house training aimed at boosting their knowledge and skills in AOD. Four NTER AOD workers have commenced AOD certificate training.

Capacity building took place in several residential rehabilitation services. This typically consisted of funding for additional staff and operational costs, to allow an increase in bed capacity. Funded organisations included: Council for Aboriginal Alcohol Program Services (CAAPS), Darwin; Barkly Region Alcohol & Drug Abuse Advisory Group Inc (BRADAAG), Tennant Creek; Mission Australia, Nhulunbuy; and Vendale Rehabilitation Centre, Katherine. The Central Australian Aboriginal Alcohol Program Unit (CAAAPU) received an infrastructure grant to allow them to complete a women’s facility.

Community education projects run by a range of organisations have great potential. Most of these involve direct agreements with OATSIH and I have had little to do with their implementation. However, I have been involved in the planning and early stages of implementation of a project undertaken by Irrkerlantye Arts, Alice Springs. This has involved development of educational resources (flipcharts, multimedia products), assessment tools and health promotion messages. The process of developing these, through workshops and consultations, has disseminated knowledge, boosted skills and created employment amongst local Arrente people. It stands as an illustration of the value of participatory processes and community development work.

2. What isn’t working?

In practice, hospital management of alcohol and drug related presentations in the NT remains suboptimal. NTER AOD initiatives did not cover the whole NT – funded detox beds were only in place in Tennant Creek and Katherine, where they showed promising signs. However, the largest volume of need is in Alice Springs and Darwin. AOD nurses were funded for hospitals but recruitment was slow due to bureaucratic delays and prioritisation of other issues within the hospital system. Uncertainty regarding timeframes was also a factor: by the time a funding agreement between NT DHF and OATSIH was signed in May, funding could only be guaranteed until end of June; later rollover of NTER AOD funds allowed for positions at each of the hospitals up until the end of October 2008. Subsequently, NT DHF was only able to offer 2 month posts. Despite this, staff have recently been recruited at each of Royal Darwin, Alice Springs and Gove hospitals, so hopefully this aspect of NTER AOD will begin to bear some fruit.

Notably, NTER AOD initiatives cannot single-handedly solve a longstanding and endemic issue in NT hospitals. Lack of confidence and expertise in managing AOD presentations continues to flow through to judgemental and unjust approaches to clients. There are major barriers preventing alcohol-dependent people being given the option of an elective medicated withdrawal (detox) within NT hospitals. The NT government has not addressed this issue in a systematic way. This is despite some supportive people in senior bureaucratic and clinical roles.

There are large numbers of marginalised people in the NT with major AOD problems who have little or no contact with treatment services. NTER AOD projects have made some advances in developing outreach models. However, we are only scratching the surface when it comes to contacting and helping some of the most disadvantaged members of our society.

3. Have there been any unintended consequences?

The structure of the AOD workforce has shifted to include a significant workforce within primary healthcare. Government policy, paradigms and evaluation and monitoring requirements now have to shift to accommodate this. Where these services fit in relation to other service providers also has to be worked through – this takes time and can upset certain people.

Recurrent funding of AOD PHC services may result in a shift of resources from the specialist AOD sector to PHC. I believe that OATSIH have made a sound decision, both ethically and in terms of service performance and mix, by arranging ongoing funding for newly established AOD PHC services. However, some NT DHF staff believe this will result in relatively less money from COAG 2007, and possibly other sources, being made available for NT DHF priorities. They suggest it may compromise operational funding for some infrastructure projects previously funded by OATSIH. Perhaps these disagreements would have arisen anyway. OATSIH funding PHC initiatives whilst NT DHF funds acute care activities seems a logical split. However, resources are finite. Allocation of funds to one area can slow the development of another. NT DHF AOD services should complement those in PHC and develop in parallel. The impact of changes to service mix should be open to discussion and debate.

The rollout of AOD services in remote PHC, already planned under COAG prior to NTER, must now accommodate advances made under NTER. In many senses this is a positive, especially since the current workforce is larger and has been established earlier than if developed solely under the COAG umbrella. However, the rapid and relatively organic evolution of these services has compromised our capacity to systematically plan and structure some COAG services.

4. How is each NTER measure performing and how should each be taken forward?

AOD PHC services have become operational and performed useful work within a short timeframe. They addressed the necessary first step of community engagement and acceptance well. Some of their key attributes include: adopting a cultural broker or partnership model involving Aboriginal and non-Aboriginal people; integrating AOD and mental health paradigms; outreach models of care; visits to remote communities; and developing alternative therapeutic approaches. Further details are available in the NTER AOD Clinical Director’s Interim Report.

AOD PHC services would now benefit from some more structured planning, service development and quality assurance processes. Consolidation of relationships with other agencies, and referral pathways, needs to take place. Formalisation of standards and processes, including those around assessment and management, would also be useful. This represents a major challenge: drawing from current evidence and knowledge but retaining the capacity for innovation. Formalised standards and processes must be careful not to encroach on the flexible and tailored approach to service delivery, relatively unbound by systems constraints, that has been a key to the early success of these projects.

A workshop around key themes and findings that have emerged from these projects would be useful in many ways: for staff debriefing, for crystallisation of key ideas from the field, to plan future services, to document key lessons in a way that maintains the advances made on mainstream models.

Strategic thinking that looks at areas of need and aims to improve coverage (ie matching service delivery to community needs) is essential. If this takes place, it may be concluded that other similar services should be established in other PHC services, both in AMSs and government clinics. If this occurs, NTER AOD PHC services represent a useful pilot to guide the planning and implementation of future services.

Outreach and family services:

Future services should consider the expressed needs of delegates to the Central Australian Aboriginal Men’s Health Congress, which I was fortunate to be a facilitator at. When discussing AOD services, delegates consistently called for services to be delivered within communities, and with the following features:

These ideas have been expressed for a long time in many circles. Out of this type of collaborative approach, new ideas and methods emerge. NTER AOD PHC services, with their outreach style, embody some of these features. Note that to implement this type of approach, which reflects the wishes of Aboriginal people, we will need to design a service that looks very different from a mainstream AOD services. Measuring output and outcomes may be difficult using conventional techniques. Hence, patience and wisdom would be required.

AOD PHC services need a commitment to long term funding in order to become sustainable into the future. This will most likely need to come from the Australian Government. The impact of constant uncertainty around the timeframe and availability of funds over the past 6 months should not be underestimated. It has required many reassurances, appeals to goodwill and strength of character. It is unreasonable to expect staff to operate in this environment into the future.

AOD PHC services are also being planned under COAG funding. Whilst there have been considerable attempts to make related initiatives under NTER and COAG complimentary, more work needs to be done on this. Strategic planning for the wider NT AOD sector is important and NT DHF, OATSIH and the NGO sector are all making useful contributions in this area. Integration with mental health could be further explored.

Reduced funding in the second year of NTER for AOD initiatives had not allowed the initiative of AOD workers in NT hospitals to bear fruit. A major factor has been bureaucratic hurdles and delays. The Australian Government and NT DHF should sort out their funding arrangements and allow for a proper trial of this initiative. There should be a clear commitment from NT DHF regarding initiatives and timetables for improving hospital AOD management in the long term.

Community education initiatives should be subject to normal cycles of reporting and review. Capacity building within the NT AOD sector should be subject to planning and review. NT DHF, OATSIH and the NGO sector already make valuable contributions to this process.

The NT would benefit from an ongoing relationship with the Dulwich Centre, to expose a wider audience to the ideas of narrative therapy, and consolidate their use by clinicians and others.

We should continue the search for new therapeutic approaches in the AOD field. We should be patient and open-minded when it comes to their trial and implementation. We should look to the interface between Western and Aboriginal knowledge systems for their emergence.

5. What progress has there been in improving the safety and well-being of Indigenous children?

The impact on Indigenous children is diffuse and difficult to measure. Adults are the target for many NTER AOD initiatives: individual counselling and group work from AOD PHC services, and hospital management for withdrawal and alcohol and drug related presentations. Community development and community education target a wider population. Capacity building within residential rehabilitation services and other AOD agencies has presumably increased the range and access to therapeutic options.

I think it is reasonable to postulate that improving the volume, range and quality of AOD services in the NT will over time assist adults to overcome alcohol and drug abuse problems and that the benefits will flow through to children through a more stable and safer living environment.

One ongoing service gap should be mentioned. Whilst all five major population centres in the NT have residential rehabilitation services, only one allows family members, including children, to stay. This is CAAPS (Council for Aboriginal Alcohol Program Services) in Darwin. On my visits to CAAPS I have been impressed by the supportive environment and educational opportunities provided to children resident at CAAPS whilst their parent/s undertake a rehabilitation program. Many people have commented on the desirability of this model, and that failure to accommodate families represents a barrier for some people who may otherwise enter rehabilitation. Notably, NTER funds allowed CAAAPU (Central Australian Aboriginal Alcohol Program Unit) in Alice Springs to complete building facilities specifically to accommodate women, a valuable addition.

6. Will the suite of measures deliver the intended results?

NTER AOD initiatives have expanded the capacity and scope of AOD services within the NT. Recurrent funding is needed to ensure sustainable outcomes. For these to have maximum impact they must be coupled to ongoing processes around quality assurance and service development. Initiatives that may help this include: the OATSIH funded NTER AOD evaluation, a strategic approach to training, and OATSIH’s work around accreditation of AOD agencies.

If the above takes place, I believe we have achieved the objective of improving the impact of AOD clinical services within the NT. Notably, we still fall far short of achieving full coverage across the NT. The Darwin rural and remote regions in particular have seen very little from NTER AOD initiatives. We should also remember many good ideas for service development remain and these should be given opportunities to develop. There are many service gaps still to be addressed.

Clinical services will only ever be one piece in the puzzle when it comes to lessening the health and social impact of alcohol and other drugs. Achieving this also requires a range of other measures, including: legislation and supply restrictions and addressing the broader determinants of health such as education, housing and employment. This concept is summarised by the classic triad of the harm minimisation approach: supply reduction, demand reduction and harm reduction.

Finally, the intended results will only be seen in the long term. Hence, we must sustain long term commitments to initiatives that show promise, have the insight and courage to modify them when necessary and think in terms of generational change.

7. Will NTER lay the basis for a sustainable and better future for residents of remote communities and town camps in the NT?

Yes, I believe it will. When one considers the high prevalence of alcohol and drug related issues, it seems imperative that we have appropriate AOD services to help address these. Development of the AOD sector has been in progress for many years. NTER AOD initiatives have provided a valuable and innovative boost to this large and complex task. Aside from straight workforce expansion, the development of outreach models, new therapeutic paradigms and the training of Aboriginal people in AOD skills have been major ongoing contributions to NT residents in these areas.

Dissemination of knowledge and ideas, the strength that emerges from personal healing and the building of social capital diffuse through population groups in intangible ways that are difficult to measure. However, we should not discount their importance. This is the very nature through which work in communities and across societies generates a positive impact. I believe the NTER AOD initiatives have delivered in these terms, due to the skills and personal attributes of the workers and the people and communities with whom they have worked.

8. What alternative measures should be considered?

PHC AOD services should become integrated with mental health initiatives and the work of social and emotional wellbeing (SEWB) units within AMSs. A broad audit of these and related services and some strategic thinking about how their collective impact could be maximised would be a useful exercise.

Regarding hospital AOD management, I have been told verbally that the Australian Health Care Agreements (AHCA) relating to NT hospital funding include withdrawal management requirements (for all five NT hospitals), though these are not currently enforced. I think we should determine whether this is true. If so, we should examine the spirit behind this expectation and see if we have remained true to it. If not, I think we should consider building such a provision into future funding agreements. Senior management within DHF Acute and AODP together with key hospital staff should together formulate a systematic approach to addressing this issue.

9. Are there other ways of working that would better address the circumstances facing remote communities and town camps?

A guide to development of AOD services for Aboriginal people in remote communities emerged from the Central Australian Aboriginal Men’s Health Congress, and is outlined under question 4. I believe it is consistent with the thinking of most people in the NT AOD field. We should seek to implement this vision.

The need to constantly search for alternative therapeutic approaches has been cited. This requires more than creative thinking from those on the ground. It requires bureaucracy to develop flexible funding models, innovative methods of evaluation and an understanding of ground level conditions and challenges. It also requires spaces to be created where open exchange of ideas can take place respectfully.

Other comments

The above discussion stems from my direct work as a doctor and public health physician in helping to implement service development initiatives across the NT AOD sector. I would now like to offer my personal reflections on some other elements of NTER.

Firstly, I believe the Warning signs erected outside Aboriginal communities are inappropriate. I am speaking of the large white signs with blue writing that read NO ALCOHOL and NO PORNOGRAPHY with more detailed and smaller writing below each heading. I assume the rationale is to make sure everyone is clear regarding standards and the law and to facilitate policing and law enforcement. However, I believe these signs are unnecessarily punitive and shaming of Aboriginal people. I believe our society must acknowledge our subconscious desire to shame Aboriginal people in response to some of the unfortunate trends that have emerged within certain communities.

We must remember that the majority of Aboriginal people are victims rather than perpetrators, much as I dislike this terminology. Constant reminders of this are hurtful. There are other ways to clarify what is legal and the implications of overstepping the law. This issue is sufficiently clouded by the complexity of dealing with Aboriginal and Western law systems that there is more damage done by fuelling resentment than there are gains from defining legal standards. Finally, a sense of shame contributes to the poor self esteem that underpins unemployment, depression, violence and range of other behaviours. Re-enforcing shame is potentially destructive for individuals and society. We must act with compassion. Even if our heads say yes to the signs, our hearts must say no.

One particular incident crystallised my views. At the end of a day, we were dropping home one of the NTER-funded Aboriginal community workers from one the AOD PHC projects. I admire this worker a great deal. With little background in health or formal employment history she quickly became a valuable contributor to the project in her role as a cultural liaison officer. She was chosen for this role through a process of community consultation on the basis of her leadership skills and personal integrity. She mixes work with duties as a mother. She shows much goodwill and patience when dealing with project requirements and the Western knowledge base and treatment paradigms. She is undertaking certificate training in AOD and her appetite for learning is impressive. As we dropped her home, at the end of a productive day, we drove past one of those signs. She noticed it and I noticed it. It seemed to hang in the air, to hang over the community. It tainted the moment, it tainted the pleasure in what we had achieved together during the course of the day. I felt ashamed to come from the culture that erected that sign. Nothing was said. But I remember the moment clearly. It felt wrong.

In short, I believe the signs outside communities should come down. They should not be replaced by a modified version of the same thing. Signs initiated and erected by communities themselves are a different story and are not the subject of these remarks.

Secondly, welfare quarantining has created some major injustices that need to be addressed. I don’t believe that everything about welfare quarantining is wrong, though I respect those who do. I think the legality of overriding anti-discrimination legislation should be more closely examined. I have heard a wide range of anecdotes about the impact of welfare quarantining.

Some people, Aboriginal and non-Aboriginal, defend the gains welfare quarantining has made in reducing the supply of alcohol and the violence that flows from this. They also cite greater availability of basics such as food and clothing. These are good people, morally and culturally sound, and their observations are rooted in the practical aspects of daily life, not in ideology. Their words should be heeded.

However, more commonly, I have heard stories of major inconveniences that stem from the systems and requirements around welfare quarantining. Like workers in communities spending a significant amount of their time driving people to town because they can’t buy food at the local store, since their money is at Woolworths. If they had chosen the local store to spend their money, they’d get half as much food. Don’t most people in modern society rely on more than one shop for their food requirements over the course of an average fortnight? Who looks after the children when they are on the round trip of several hundred kilometres to Woolworths?

Other Aboriginal people expressed some frustration and angst over having to phone a call centre to obtain any variation to their welfare payments, based on circumstance. At one stage, the major call centre was in Tasmania, adding to the challenge of explaining themselves. One man spent all day trying to get the money to change the tyre on his car!

Many of these people are highly functioning and lead busy lives that don’t need another inconvenience.

Still others express relative indifference at welfare quarantining, especially those who live in isolated locations where there is only one place to spend their money anyway. They are just a little bemused at yet another round of pointless paperwork.

One long term community worker (non-Aboriginal) was bemoaning the fact that for years it was impossible to get any kind of welfare quarantining, even if everyone was asking for it. Now it’s been applied to everyone. Many Aboriginal people observe that whilst it may be fair to control the finances of those whose spending patterns are harmful to themselves and those around them, why can’t this same rule be applied to non-Aboriginal people, including drug addicts and alcoholics. I have to agree with them.

Overall, I think the present system of welfare quarantining is unjust and should be substantially modified. Complete abolition of it is one legitimate option but would sacrifice some genuine gains in some areas. At the very least it should become more discretionary, be subject to ongoing consultation with Aboriginal people and apply across the board to the entire Australian population. The systems for assessment and review that would arise from such an approach are another story.

Thirdly, I think government must pro-actively address the damaging phenomenon of labelling and generalisation. It is a common complaint from Aboriginal people that they have all been ‘tarred with the same brush’. At the Aboriginal Men’s Health Congress, participants described the burden and cost of all men being labelled as child abusers and alcoholics. The Little Children are Sacred report acknowledged the injustice and social cost of this perception. This failure to acknowledge diversity is hurting Aboriginal people and substantially diminishing the quality of social debate. It impacts on the self-esteem and pride of a people and obscures the deeper truths of their lives. It fails to acknowledge stories of triumph and success, sometimes under hugely adverse circumstances, that are just as common and need to be built upon. It prevents people from moving on. It denies the role and responsibility of white culture in creating our present situation and its need to engage in the healing process. It leads to unjust and simplistic policies, like certain elements of NTER.

The media should take some responsibility for this phenomenon.

At the very least, I believe the Australian Government should acknowledge the generalisations and labelling that have led to some of the unjust aspects of NTER. They should encourage more informed social debate, and lead by example. They should encourage the media to adopt a Code of Conduct around reporting on Aboriginal issues and NTER.

Finally, I would summarise with the remark that it is impossible to say whether NTER has been good or bad, since it contains elements of both. It is a complex, multifaceted initiative that has evolved substantially since its inception. Often its impact turns on the quality of people involved, rather than the technical aspects of each initiative. I believe there has been value in the raised awareness and increased resources it has brought. Our challenge is to reform NTER in a way that is just and maximises social gains.

I have valued the opportunity to expand the AOD sector using NTER funds. I believe this is a task whose importance was identified prior to NTER and stemmed from community consensus. I hope the gains it has achieved will be consolidated and fully incorporated into mainstream services.

Thank you for the opportunity to contribute to the NTER Review.

Please feel free to contact me if I can be of any further assistance.

Yours sincerely

 

Dr J J Brownscombe MBBS(Hons) DCH MPH FAFPHM
NTER AOD Clinical Director

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