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HEALTH AND MEDICAL SERVICES

This section covers primary health services, mental health, drug and alcohol and environmental health.

25 PRIMARY HEALTH SERVICES

This research is informed by a holistic notion of health which encompasses a range of social determinants hence, the coverage given to issues such as welfare, transport and employment. In addition the specific issues relating to cultural diversity, disability and mental health have also been examined. This section of the report re-focuses the emphasis more explicitly and directly on medical and primary health care as well as public health and health promotion, which straddle both social and medical areas.

The Department of Health is the principal health authority in Western Australia and its role is to manage a comprehensive range of health and health-related services to all Western Australians, including health promotion, health protection, diagnosis, treatment, rehabilitation, continuing care, support and palliative care. These services are provided through a range of people and organisations. The Department of Health aims to ensure that all the components of this diverse system work together to deliver the best possible health care to all Western Australians when and where they need it. The Department of Health’s mission statement ‘…is to protect, promote and restore health, and to care for the sick and disabled people of Western Australia’ (Healthy Horizons, 2001: 3). How successfully it does this is of course the subject of on-going debate. Whilst some of the ways in which the Department of Health could work differently have inevitably been raised in this report these need to be qualified in terms of some of the positive developments that have been made and/or are going to be implemented. A further qualification relates to issues of funding and rising health care costs; which this study does not specifically address. That is not to deny funding isn’t a complex and ongoing problem however, it is beyond the scope of this study to adequately and fairly address all the encompassing and complex funding agreements between state and federal levels of government. The Department of Health works closely with the Federal Government, Local Government, health agencies, and non-profit and private organisations.

Its policy direction and strategies are also influenced by international bodies such as the World Health Organisation, particularly in the areas of public health, preventative programmes and health promotion.

Health service programmes include:

• Public Health: Aimed at reducing the incidence of preventable disease, injury, disability and premature death through Health Promotion and Health Protection.

• Community Health: Aimed at optimising the health of individuals and families within their normal living environment through health promotion at a local level, screening, immunisation and treatment of infants and school-aged children within community health-care centres and schools and the provision of basic health care to special needs groups such as Aboriginal people, women, people with severe chronic disability or disease, people on low incomes and people living in remote areas of the State.

• Hospitals: Aimed at providing accessible hospital care according to recognised standards of quality in a way that is acceptable to clients.

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• Continuing Care: Aimed at providing support services for people with moderate to severe functional disabilities and their carers, and for people with terminal illnesses through nursing home and hostel services, hospice services and Home and Community Care (HACC) services (i.e. home nursing, home help, transport services, home maintenance, delivered meals, respite care).

• Mental Health: Aimed at providing accessible hospital and community-based care to individuals with mental health problems and mental disorders to recognised standards of quality; and to provide programs that are known to be conducive to improving mental health.

• Dental Health: Aimed at promoting and improving the oral health of Western Australians through services directed towards school children, aged people, financially and geographically disadvantaged people and other at-risk groups.

The funding models for Health and Medical services include purchaser provider and case mix funding. Purchaser provider is a tendering system whereby specific services are brokered by the Department of Health. Hospitals are funded through case mix which is specifically linked to Diagnostic Related Groups with acute/specialist care areas attracting higher levels of funding. The key principles that guide the purchasing of health services in Western Australia for 1999 to 2003 include:

• Localised Health Care

• Purchasing for value, and

• Innovative service delivery (Health Horizons, 2001: 3).

Current health policy directions revolve around the National Health Priority Areas. These have been identified as specific areas that impose high social and financial costs on Australian society and where significant gains in the health of Australia’s population can be achieved. The National Health Priorities Areas (NHPA) initiative is Australia's response to the World Health Organization's global strategy Health for All by the Year 2000 and its revised strategy Health for All in the 21st Century.

The NHPA initiative is a collaborative effort involving the Commonwealth, State and Territory governments and the non-government sector. It provides a framework for national action to achieve health gains in six identified priority areas:

• cardiovascular health

• cancer control

• injury prevention and control

• mental health

• diabetes

• asthma

Other recent policy directions also include a focus on rural health services.

In relation to cardio vascular disease and diabetes in particular the Department of Health in Western Australia has devised a Strategic framework for primary prevention of diabetes and cardiovascular disease in Western Australia 2002-2007.

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This strategic framework aims to work in ways that integrate public health strategies with primary health initiatives and reforms in Aboriginal and rural health areas.

Primary prevention is also emphasised in the 2000 Department of Health WA report New Vision for Community Health Services for Future. Again the approach is to work in an inclusive and integrated way to involve the diverse arms of the health system to include programmes that enable early intervention, health promotion, community development, a skilled workforce and collaboration between key stakeholders. From this overarching strategy the Healthy Lifestyles framework has been devised, the aim of which is to reduce or eliminate lifestyle and environmental risk factors. All of these developments are influenced by the World Health Organisation which at the international level has endorsed a global non-communicable diseases (NCD) strategy (WHO Global Strategy for the Prevention and Control of non-communicable diseases).

The Department of Health is also involved in the Home and Community Care Program (HACC) which funds programmes state-wide to support community-based programmes that offer home-based care for the disabled and elderly (Healthview, 2002: 13) (for details see the section on Seniors Services 24.1). Thus, demonstrating the complexity of health service delivery in the State and how the boundaries between the medical and the social overlap.

Health Promotion

The overlap and intersection between the social and medicine is perhaps most apparent in preventative and public health strategies, particularly through health promotion programmes. As O’Connor-Fleming et al. contend ‘there has been a clear and very impressive decline in preventable mortality in most developed countries, including Australia since the 1960s’ (2001: xiii). Whilst of course some qualification is needed in relation to the major concerns surrounding Aboriginal health in comparison to the rest of the population (see Watson, et al., 2001), preventative health strategies and health promotion have played a part in some of the positive health outcomes in recent years particularly associated with declining cardio-vascular and injury mortality rates for the population as a whole (O’Connor-Fleming, et al., 2001: xiii).

The Ottawa Charter for Health Promotion (1986a) is the seminal document underpinning the WHO and Australian (including Western Australian) directives in relation to public health and health promotion practices. The Ottawa Charter is based on five essential components:

• consideration of public policy

• monitoring of both social and physical aspects of the health environment

• educating communities in health advocacy and action

• develop individual skills in health advocacy

• reorienting all community strategies towards implications of preventative strategies (O’Connor-Fleming, et al., 2001: 6)

Whilst health promotion and prevention are increasingly seen as important in maintaining healthy populations and decreasing health care spending at present it only represents 2% of the total health care budget (Australian Institute of Health and Welfare, 2001b).

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25.1 Outline of Services

The City of Gosnells local government area comes under the Canning Division of General Practice. It also sits on the border of Armadale and Bentley Health Services and as such is served by both Armadale Hospital and Bentley Hospital. For specialist medical care residents of the City of Gosnells local government area often have to travel to Perth City centre hospitals, Fremantle or Sir Charles Gardiner hospital in Nedlands. • Armadale Health Service is made up of a Government funded Non Teaching

Hospital, Aged Care & Rehabilitation Service, Community Health Service and Mental Health Service all located on the one site.

• Bentley Hospital is an integrated Health Service that provides a range of services including; Surgical, Medical, Obstetrics, Gynaecology, Allied Health Outpatients, Aged Care and rehabilitation, Community Health and Mental Health Programs.

• General Practitioners: There are 57 General Practitioners in the City of Gosnells local government area working from 18 practices that range from solo practices to large group practices with 13 doctors (source the Canning Division of General Practice).

Derbarl Yerrigan is an Aboriginal health service managed and staffed by Aboriginal medical, health and welfare workers. It is part of the Aboriginal Health Service (Department of Health) (for full details on Aboriginal health services see section 19).

Community Health Services: Both Bentley and Armadale Hospitals also consist of community health sections. They include teams of Child Health Nurses, School Health Nurses, Health Promotion Officers, Aged Care Teams and allied health specialists. Armadale Health Services have recently won funding to improve services to older people through improved links between emergency, outpatient and community health services.

There are also various outpatient clinics for targeted health issues including incontinence and diabetes clinics.

Silver Chain provides clinical care services to people at home who come under the HACC programme and Department of Veterans Affairs. They also provide services to non-HACC clients in clinics held in Bentley and at Armadale Hospital.

Health Promotion: In the City of Gosnells local government area health education and information is delivered through Health Promotion Officers working in the Community Health Departments of regional Health Services. They work with Child Health Nurses, School Nurses and other community organisations to promote Health Department programmes and health priority areas. In the City of Gosnells local government area health promotion is also delivered by a range of services working in the Welfare, Aboriginal, Health and Education Sectors. Services in the area that may not explicitly identify their programmes as health promoting, instead using terms such as ‘life skills’, are also involved in health promotion activities. For example, services that work with youth in neighbourhood centres are indirectly involved with ‘health’ and acknowledge the importance of preventative strategies in relation to issues such as mental health and solvent and drug use (for details on mental health and drug issues see sections 26 and 27 respectively). Some services also have health promoting activities more directly and immediately related to health, such as the adoption of some primary schools in the Gosnells area, of healthy eating practices (two pieces of fruit a day). Pharmacies are also an important source of health information and referral in the community. Health promoting practices may also occur in more medical settings such as that of local general practitioners who may be instrumental in encouraging and supporting programmes such as the quit smoking campaign.

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Women’s Medical Services and Health Promotion: The Gosnells Womens Health Service currently has a general practitioner available on two half days a week. This is in stark contrast to other women’s health centres in the metropolitan area who offer a full range of medical and clinical services to women. It also holds information sessions on various health issues and educational programmes in schools, Southeast Metropolitan College of TAFE and through other community groups. These are to promote healthy lifestyle choices and to disseminate health information to women in the community.

Palliative Care: Palliative care is provided through general practitioners and Silver Chain has a palliative care arm and hospice funded through the Department of Health.

Ambulance Services: The City of Gosnells local government area is covered by a St John Ambulance service. Emergency services represent 30% of St John Ambulance work load. Non-emergency transportation is mainly used by nursing homes and hospitals. This type of work accounts for over half of the service's on road activities. To ensure the maximum number of ambulances is always available for true emergency situations, St John Ambulance introduced Patient Transport Vehicles in 1994. These dedicated vehicles are available to people who require non emergency transportation, and are manned by trained Transport Officers capable of administering emergency medical attention should the need arise.

Allied Health Services: In the City of Gosnells local government area there are numerous private services that respond to the allied health needs of the community. These are generally user pays and include physiotherapists, chiropractics, optometrists, speech therapists, dental health, pharmacists, podiatrists, chiropodists, sports physiotherapists, naturopaths, homeopaths, masseurs and other alternative health services.

25.2 Findings

General practitioners and other medical services: Findings from Phases 2 and 3 of the study identify a shortage of General Practitioners and medical services within the local government area and a lack of out-of-hours services. This has the potential of placing increased pressure on hospital based out-patient services. The following quotes indicate problems are experienced across suburbs and capture some of the concerns people expressed in the Phase Three surveys:

Medical Services outside of normal business hours preferably 24 hrs – with bulk billing facilities (Maddington)

Availability of medical services on w/ends in this area is very poor. Nearest emergency care is Armadale Hospital (Beckenham)

I believe more doctor clinics are needed. I have to travel a fair way to get my child’s doctor because the Maddington area does not have enough good doctors (Maddington)

As a health care issue, there seems to be a shortage of GPs to service the area. For example, one must give three days notice to see a GP. Perhaps the large population/customer base could be used as part of an advertising scheme to lure new GPs and other paramedical practitioners to the City (Thornlie)

Kenwick needs a good health centre and a chemist that’s open after five o’clock instead of going to Gosnells or Thornlie or Cannington (Kenwick)

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… more doctors offices ‘cause there is only one in our area and it stinks when they say they are not taking anymore people.. so that means we have to go down to Maddington, ‘not happy Jan’! (Gosnells)

My main concern is the absence of small doctor’s surgeries. They are now all large medical centres where they don’t even want to give you the time of day and they herd you in like cattle… and you get 10 minutes to say your problem or you get charged for two sessions (Thornlie)

… amenities have reduced in Gosnells – not increased with population growth. Resident for 32 years… doctors, hospitals to name two recently (Gosnells)

… emergency services hospitals with greater capacity for emergencies and not sending people on (Gosnells)

The perception there are shortages may also be related to long waiting lists and short consultation times. However, figures supplied by Canning Division of Practice appear to back the perception there is a real shortage. Accordingly, there are 57 practising practitioners working within the City of Gosnells local government area. When compared to available national figures from a 1994 report, which show there were 180 General Practitioners per 100,000 population in major urban areas and 95 per 100,000 population in rural areas, the ratio in the City of Gosnells local government area is low with 57 per 80,517 (which is equivalent to 71.25 per 100, 000 population) (ABS, 1994).

A recent health plan for youth in the Armadale/Gosnells region, entitled An Investment in Youth Health and produced by the Canning Division of General Practice also support these findings. The Report states in 2000/01 ‘there were 207 full-time equivalent GPs practicing in the south east corridor with less than one third practicing in the Armadale/Gosnells region’. They report this compares unfavourably with all other local government areas within the Canning Division and the wider metropolitan region. The GP per population ratio for the Armadale/Gosnells region (1:1658) is 32% higher than the Perth average and more than double (110%) the ratio for all other local government areas in the Division (1:789) (Canning Division of Practice, 2002: 26).

Seniors Services identify there is also a difficulty in accessing home visits by General Practitioners and that there are long waiting times. The researchers were informed by one General Practitioner working in the City of Gosnells local government area that it is currently not cost effective for General Practitioners to make home visits as the daily practice takes up all available working hours. The lack of General Practitioner cover is significant in relation to policy aims to keep people independent in their own homes and in the upward pressure it places on hospital emergency units.

Services working with people on low incomes also claim there is a lack of General Practitioners willing to accept bulk billing. However, participants of focus groups in Phase Three of this study indicate they do not have problems accessing doctors who bulk bill. These contradictory findings may suggest that the availability of bulk billing practices across the City of Gosnells local government area is patchy.

Youth specific health services: School Health Nurses, a youth focus group and some respondents to the youth survey carried out for this research identify that there is a need for health services for youth, particularly in relation to sexual health. Schools currently operate within Department of Education guidelines that monitor sexual activity of minors and it is felt by some that this will inhibit students coming and speaking to School Nurses and Counsellors about sexual health issues. This emphasises the need for an independent medical/health service for youth is acute.

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The Canning Division of Practice has completed a proposal for a youth specific health service entitled Youth specific health services: An Investment in Youth Health: A business plan for the development of a youth health service in the Armadale/Gosnells region (prepared by J. Salapak, 2002) for submission to the Department of Health WA and the Federal Government. The proposed centre is envisaged as both a youth centre and a counselling and medical service. It emerges out of the Talking Health Report from a 1999 consultation with youth.

Beckenham Child Health Centre: Child Health Services report that the centre is inadequate by today’s standards of health care delivery. Nurses are without computer access and clinical space is inadequate. The lack of computer access is significant as computers are a priority in enabling staff to create networks with other agencies and foster effective working relationships.

There is no public transport that goes directly to the centre and the Beckenham Train Station is approximately 1½ kilometres away. The building is not inviting to look at and therefore is not a welcoming place for mothers to bring their children. This was reported to have a detrimental affect in encouraging clients to access the service. With new housing estates and affordable housing close by it is also feasible that the centre will have an increase in demand for services with young families moving into the area.

With the present restructuring of child health services the future of individual child health centres is uncertain but in relation to this research the circumstances of the Beckenham Child Health Centre serve to remind planners of the need to position centres to optimise access. Further, it highlights the importance of purpose built facilities that meet the needs of administration, clinical services and mothers and babies.

The need for better facilities is also identified as an issue for School Nurses.

Home and community based medical care: Services working within the Community Health Sector identify that there is a gap in services in relation to post hospital care for people who are discharged from hospital and have post surgery or ongoing clinical care needs. For those with the resources it is possible to secure private nursing cover at approximately $30/hour. But for people with low incomes or financial constraints this support is difficult to obtain. This is a particular problem also for seniors who require ongoing treatment and assistance with medications.

Recently Armadale has seen the closure of the Kelmscott Silver Chain home nursing services. The centralisation of this service at Bentley Hospital means that people must travel to Bentley or Armadale hospital for dressings and nursing care if they are not serviced by home visits. There are further issues relating to medications and dressings and this was mentioned as a concern by Gosnells Community Support Service. This is because support workers employed to undertake personal and domiciliary care are not allowed to give medication to clients or change dressings. Silver Chain workers may not attend to clients every day or only once a day. This means that in-between visits clients are reliant on family, friends and volunteers to assist with medications and dressings. Key informants from Silver Chain also raised this issue and recommend the use of Blister Packs for medications is the best strategy to assist people with their medications.

At the local level there is already some response to these kinds of issues through Armadale Health Services who are taking part in a national programme called the National Demonstration Hospitals Program (phase 4) which aims to improve the links between hospitals and community services to provide better discharge services and outreach for the aged.

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Specialist services: Several key informants report that Armadale Hospital has been unable to obtain the necessary specialists to work at the hospital. The result is that patients must be referred to other Metropolitan hospitals in Perth City such as Sir Charles Gardiner, Royal Perth and Fremantle Hospital. The need for specialists in the local area was also raised by services working in the Disability Sector and by a focus group with carers, especially in relation to those who had children with complex medical and therapy needs.

Service providers and several survey respondents in Phase Three of the study also note that people must travel to Perth, Subiaco or Fremantle for many specialist services such as Chemotherapy and Radiotherapy. This can lead to very long and difficult days for many people, especially for the more frail aged. Given the issues surrounding transport this is seen as a major issue for the residents of the City of Gosnells local government area. As illustrated below:

I’m having to go to RPH, Shenton Park campus, for my hip replacement surgery next Friday. I would much rather to have been able to have it done in Armadale or Bentley (Maddington)

I would like to say since the No 9 and 13 buses have been taken away the bus availability is poor and the remaining bus services that go to the city do not go past King Edward Hospital, which I need right now since I’m pregnant (Beckenham)

Equity in access: The research identifies that the residents of the City of Gosnells local government area may have varying levels of access to services according to the types of services available at each hospital, variations in population pressures on regional services, and so on. Moreover they may find that when moving between suburbs within the City of Gosnells local government area this could mean changes in treatment regimes and special programmes, such as quit smoking or counselling services.

The City of Gosnells local government area is divided and overlayed by different health service boundaries. Armadale Health Service covers most the suburbs with Bentley servicing Beckenham and Kenwick. However, this changes in relation to mental health service boundaries, public/population health services and GP divisions of Practice. Because these boundaries are not uniform or consistent this mitigates against coordinating service delivery and has important implications in relation to the current focus on multipurpose ‘one stop shop’ centres (for full findings on issues relating to Service Delivery see section 18).

Family planning and women’s health needs: Participating service providers working with women identify a need for family planning services in the City of Gosnells local government area. Women currently need to travel into Northbridge to access this. Key informants and services working with people from culturally and linguistically diverse (CALD) communities also identify there is a severe shortage of female General Practitioners in the local area that can attend to women from CALD backgrounds, especially for women from Islamic and Muslim religion. This is very important particularly in relation to pap smears, obstetrics, child birth, lactation care and family planning. They also noted that the Gosnells Women’s Health Service has limited medical services.

In some cases the perceived shortage may be suggesting a lack of knowledge rather than unavailability. However, in the case of family planning for instance there is no service in the local area and so it is an issue of availability.

Key informants state it is important to provide services that feel welcoming and non-bureaucratic in order to provide culturally appropriate and accessible services for Aboriginal and CALD women.

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Culturally appropriate services: One focus group with Aboriginal residents and several service providers working in the area of health report that Aboriginal and people from culturally and linguistically diverse (CALD) communities are hesitant to access mainstream health services. Child health services and other community health service providers report that they have few Aboriginal or CALD clients (for further findings in relation to these issues see the section on Family and Children 22) (for full findings on Service Delivery see section 18).

The focus group with Aboriginal residents also highlighted how past welfare and family policies have contributed to perceptions of being ‘judged’ and real fears about children being taken away. This leaves them with some disquiet about child health home visits which points to the need for more Aboriginal workers in this area. They stated however that a children and mothers group (modelled upon one in Rockingham Women’s Health Services) and a drop in centre where Aboriginal mothers and children can informally meet would be welcomed.

Lack of participation in health prevention services: One service provider identifies a general lack of participation and accessing of services that are provided. People generally only access health services when they are sick or at crisis point. This may point to a need for more educational programmes on the benefit of preventative and promotional services. However, it may also speak to a need for more locally based and free programmes and to the need to look at alternative points of delivery, for example the work place, for people who are already time constrained.

Lack of knowledge: Some services state that appropriate information is not reaching the people who need to know. People must be very active and literate to find out what they are entitled to and how and where to access it. This raises issues of equity in health care.

A focus group with residents from the Aboriginal community also identify the need for more knowledge about services and state that Derbarl Yerrigan needs to be advertised more. Information is currently spread by word of mouth and is therefore ad hoc. This is especially difficult for Aboriginal people who come to live from outside the area. Families who have lived in the area for a long time are interlinked and know more about services. They also highlighted there are issues for Aboriginal families when trying to access Aboriginal specific services because of the politics surrounding the need to establish an Indigenous ‘identity’ before accessing services.

Lack of integration in services: One major service provider identifies a need for health and medical services to work with a more coordinated approach in the delivery of services (for full findings in relation to Service Delivery see section 18).

26 MENTAL HEALTH

Mental health has become an increasing concern in Australia and as such is categorised as a National Health Priority Area. Since the National Mental Health Strategy was initiated in 1992 significant changes have been made in response to mental health issues. The Australian Institute of Health and Welfare (AIHW) 1998 Report on mental health in Australia states that ‘Mental disorders are taking a high priority on the health agenda for Australians due to their common prevalence, the level of disability they are associated with, high direct and indirect costs, and the heavy burden of human suffering, including stigmatisation, that they impose (1999b: 1).

The importance of good mental health in enabling individuals to socially interact and reach their potential fully in society cannot be overstated. Mental health disorders can affect every facet of an individual’s life, such as family and other relationships, education and work opportunities and so on.

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Mental and emotional ill health may be triggered, or be the consequence of, various stressful factors such as unemployment, lack of economic resources, bereavement or family breakdown. Mental health is also related to larger political and social events such as the experiences of many Aboriginal and Torres Strait Islanders through the Aboriginal Protection Acts, as well as for some culturally and linguistically diverse groups, particularly refugees who are displaced and escaping violence. Mental health disorders are not easily definable and cover a range of conditions, these are described in the AIHW 1998 Report as, ‘cognitive impairment and disabilities, phobias, panic attacks, drug-related harm, anxiety, post traumatic stress disorder, personality disorders, depressive disorders, schizophrenia and psychoses’ (1999b: 3). The report also notes that depression and anxiety are becoming more commonly identified as issues of concern not only in Australia but also a number of other western developed countries (1999b: 2).

According to the Australian Institute of Health and Welfare 1998 Report most mental health services in Australia are ‘provided through primary health care, private specialist care and community mental health services (1999b: 6). In recent years there has been an increased emphasis on providing treatment through community and out-reach care outside of hospital settings. The idea is that people are able to stay in their own homes and familiar surrounds as much as possible. Hospitalisation is then only reserved for the most extreme or difficult cases. Herman (2000) confirms this trend in Australia, noting that it reflects those of other western developed countries, also noting that specialist services emphasise treatment of psychosis and that this may place a heavy load on primary health services that then have to cope with the increasing incidences of depression and anxiety.

Herman (2000) acknowledges the importance of multidisciplinary mental health teams, primary health services and government and non-government agencies, families of those with mental health problems and of course the people who are experiencing mental health issues themselves. However she qualifies this when she goes on to say ‘All these resources exist but their efforts are hindered by their historical legacies of separation from one another’ (Herman, 2000: 510).

In addition to the move toward more community based and out-reach care the importance of prevention and health promotion in relation to mental health issues is also seen as a major strategy. The Australian Network for Promotion, Prevention and Early Intervention for mental health has been funded by the Commonwealth Department of Health and Aged Care for 2 years, from Dec 1999 to November 2002. This comprises of a national network of people from a wide range of sectors, in relation to good practice in promotion, prevention and early intervention for mental health and suicide prevention across the life span. Established by the University of Flinders, the network has a National Action Plan for Promotion, Prevention and Early Intervention. It identifies key strategic areas for promoting good mental health and lists them as homes, childcare, education, health, welfare, housing, corrections, community, entertainment, sports, leisure, arts, employment, business, financial, media and so on (http://auseinte.flinders.edu.au). Furthermore, it identifies that mental health promotion and prevention needs to occur across the lifespan.

This initiative has been further developed with the release of the Action Plan 2000 and a Monograph 2000 which are aimed at providing the policy and conceptual framework for the promotion, prevention and early intervention for mental health. These documents have been developed as a joint Commonwealth, State and Territory initiative and were released in November 2000.

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Early intervention, prevention, promotion and education at a number of levels are considered necessary to address the problems of mental health. The AIHW 1998 Report and the National Action Plan for Promotion, Prevention and Early Intervention both refer to the Ottawa Charter 1986 as providing a framework for creating supportive environments, developing personal skills, developing healthy public policy, reorienting health services toward prevention, and strengthening community action (1986: 111). This more holistic view reflects the underpinning philosophy of the Gosnells Community Health Needs Study, that is, where people live, educational opportunities, places of employment and so on need to be situations and places that enhance mental health and social wellbeing. The AIHW 1998 Report notes that ‘Barriers to the creation of mentally healthy environments need to be identified and eliminated’ (1999b: 112). The report also raises concerns about the levels of knowledge in the community in relation to what kinds of responses, treatment and counselling is available for people who are experiencing mental health disorders, problems or issues.

The general consensus is that many mental health problems are undiagnosed or treatment needs unmet, particularly in specific populations such as youth or those who are homeless. The complex nature of mental issues means that services must be flexible and integrated. Both Bentley and Armadale Health service use multidisciplinary teams and community based out reach care. The emphasis is on community based care utilising similar approaches to those discussed above.

26.1 Outline of Services

Armadale Mental Health Services: the major provider of mental health services in the area is Armadale Mental Health Services, covering Armadale, Kelmscott and most suburbs within the City of Gosnells local government area. The service has three main components:

• child and adolescent

• adult and

• older people

The philosophy of the service is underpinned by a community model of care. As much as possible, treatment and care take place in the client’s own home with clinics close by in the community. At the moment there is a community clinic in Kelmscott and one is also planned for Gosnells. A business plan has been devised and accepted as feasible however, funding from the Department of Health has not been forthcoming for the Gosnells clinic. The plan has been ‘approved in principle’.

The service works as a multidisciplinary team, including psychiatrists, social workers, physiotherapists, occupational therapists, community mental health nurses and so on. There are also specialists who deal with particular issues such as suicide. The service is ‘community based and community driven’ and employs approximately 164 staff. The single common process used to determine client needs and treatment regimes is risk assessment. The teams go out into the community and all provide services in the client’s own home.

In addition to the community based services there are also some in-patient beds provided at Armadale Hospital. For a population of 200,000 there are only 22 beds in the Armadale hospital. Older people (special unit) have 8 beds set aside whilst younger adults have 14 beds. Clients are only admitted as in-patients if they are assessed as seriously at risk of harming themselves or others. Sometimes clients may have to be sent to Fremantle or Bentley Hospitals.

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Treatment of mental health issues have progressed considerably in recent years with intensive support schemes and advances in modern medication.

Bentley Mental Health Services: The Mental Health Program is a large part of the Bentley Health Service, accounting for 51% of the overall budget.

• WAY Centre Adolescent Unit: is a state-wide specialised inpatient unit that provides services to adolescents aged 13 - 18years in the realms of assessment, containment during crises, and ongoing inpatient management when indicated. Admissions are provided to patients on both voluntary and involuntary bases. Planning in relation to inpatient management and discharge planning is performed in close collaboration with community-based services, employing tele-conferencing when appropriate, and a close nexus with the Transition Unit is maintained.

• WAY Centre Transitional Centre: Is a state-wide 'partial hospitalisation' programme for adolescents aged 13 -18 years. The program provides intensive support for either inpatients of Adolescent Unit or those adolescents who require more intensive support than can be provided in a community clinic setting.

• WAY Centre Child Residential Unit: Is a state-wide residential facility providing assessment, treatment and rehabilitation of children aged 8-14 years with severe emotional and behavioural problems, generally with prominent “externalising” features (conduct disorder, oppositional/defiant disorder, ADHD) in the context of multi-system dysfunction, who have been unable to benefit significantly from community-based interventions.

• WAY Centre Home Intervention Service (Brief Home intervention Program, “B-HIP”): Intensive cognitive behavioural intervention programme for children and adolescents aged 8-14 years. The module is provided as a set programme of 10 sessions. The multi-disciplinary team of mental health professionals provides the service to the individual and the family usually in the child’s/family’s home. Liaison is maintained with the child's school and relevant community organisations.

• WAY Centre Bentley Family Clinic: Provides comprehensive multi-disciplinary specialist mental health service that provides assessment and intervention on an individual, family or group basis. Intervention may be clinic or home-based. This service is part of a collaborative regional service called East Metropolitan Child and Adolescent Mental Health Service (EMCAMHS). Armadale, Kalamunda, Bentley and Swan Health Services all participate. There is a single point of entry for consumers and uniform policies and procedures shared by all the health services.

• Adult Mental Health Services: include 50 inpatient beds, outpatient service, and community services (including rehabilitation services). The Aim of this programme is to prevent admission to inpatient facilities.

Range of Services include: Consultation and treatment for psychiatric symptoms and Illness in the community/outpatients, inpatient services, follow-up treatment for those patients admitted to the Mills St Centre, Community Support and Rehabilitation programme.

• First Psychosis Liaison Unit

• Extended hours service

• Bridging and outreach services

• Jarrah Rd Centre – Independent living skills assessment and rehabilitation

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• Patricia St Drop-in-Centre

• Community Disability Housing Program

• Bentley Older Adult Psychiatry service comprises: 48-bed inpatient unit for the mental health care of seniors, Day Hospital, Outpatient service, and a Community program that provides assessment and treatment in the home or residential facility. Services are also provided to carers.

Kelmscott Children’s and Adolescents Mental Health Service: This service caters to the needs of children up to the age of 18 years of age. It was established three years ago as the area was deemed to be in high need. The centre has a mandate to work with the most severe end of mental health issues although deals with a range of mental health concerns ranging from the less severe and temporary through to ongoing and more serious issues such as suicide or suicide ideation.

The clinic offers free individual counselling as well as family and group work from a Social Worker, Clinical Psychologist and Community Health Nurse.

It currently has a 16 week waiting list and a suicide intervention officer that will see people within 24-48 hours.

It refers children who are at high risk and in need of in-patient residential care to Bentley Mental Health Services or Princess Margaret Hospital.

Community Support: There are a number of community based groups that operate to support people and families living with mental illness. The Association for relatives and families of the mentally ill and G.R.O.W. are two well established and widely operating groups.

Youth Counselling Services: There are various counselling services geared towards youth and families who are experiencing problems with teenage children. Many of these are based on a ‘user pays’ model but there are some that are available free or at cheaper rates. Those in the local area include:

• Minnawarra House: Situated in Armadale this service is for youth and/or family counselling. The waiting list is 2 weeks but they will see clients sooner if urgent. $40 – waged or $20/session unwaged – negotiable.

• Building a Balance: Is a Communicare service and situated in Cannington. This is a parent and adolescent counselling service. It will see clients in 24hrs if there is a crisis, otherwise the waiting list is approximately 2-3 weeks. This is a free service.

• Relationships Australia: This service is situated in Armadale. General counselling waiting list is 1 week. Costs start at $20, up to $75, depending on income. Specialist Pregnancy Counselling Service: free sessions for women needing counselling for an unplanned pregnancy or post termination counselling.

• Youth Focus: An outreach programme that will come to a young person, mostly for hard to engage young people.

• Centrecare: A service for young people and parents that offers mediation and counselling for families in conflict. This service is situated in Cannington and is free.

Note: This information was supplied by Gosnells Senior High School and a recent study on youth health needs carried out at the High School (Department of Public Health, UWA, 2002).

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Counselling Services: Various services and welfare organisations working in the City of Gosnells local government area offer general counselling by trained counsellors and social workers. There is also more targeted counselling for specific issues and problems such as post natal depression, domestic violence, drug and alcohol addiction, youth suicide, and Post Traumatic Stress Disorder. Services providing counselling include:

• Gosnells Women’s Health Services for women

• Boogurlarri Community House

• Derbarl Yerrigan for Aboriginal people

• Wattle House (for culturally and linguistically diverse groups)

• Gosnells Community Legal Services

• Southern Rivers Christian Church (3 trained counsellors)

• Starick House

Some services also have psychologists available for example, Gosnells Women’s Health Services and Drug ARM.

26.2 Findings

Increasing levels of mental health related illness: A significant number of participating services across sectors state they are seeing an increasing number of clients with mental health concerns. Welfare services indicate that mental health issues are an underlying causative factor in many people seeking welfare support and emergency housing. It was also reported that mental health problems may also be linked to factors such as neighbourhood disputes. Service providers across sectors also suggest whilst mental health problems may be related to social isolation they report they are also finding people have other underlying problems. These include:

• Those who have suffered from torture and trauma and who have lived in refugee camps or who have been interned for long periods of time

• Lack of family supports

• Unemployment

• Illicit drug use

• Alcohol abuse

• Relationship breakdown

One General Practitioner states that men are at particular risk due to unemployment, alcohol and drug abuse, and relationship breakdown and reports a specific need for assistance for single fathers and men who are experiencing these issues.

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Whilst we cannot simply cite cause and effect in terms of unemployment, economic disadvantage or social isolation in relation to mental health there is evidence to suggest that where people are gainfully employed and economically and educationally advantaged that the stress and strain of modern life can be ameliorated. As one service provider points out, the provision of adequate and accessible recreational and leisure activities may also be considered a ‘protective factor’ in terms of preventing mental health issues. Certainly in terms of social isolation, for example, work in the area of aged care has shown that social and recreational activities assist in promoting a sense of wellbeing and belonging. The socio-demographic profile outlined in section 9, indicates that the City of Gosnells local government area has pockets of high unemployment and large areas of economic disadvantage. This may be a predisposing factor in the high incidents of mental health problems reported by service providers. However, whilst people who are economically and socially disadvantaged may experience difficulty accessing treatment or go undiagnosed this is not to say that the more economically advantaged do not also experience mental health problems. For those who are working long hours or balancing the competing demands of employment, childcare and debt burdens may also experience distress and anxiety.

In research such as this it is difficult to explore fully issues such as social isolation and the extent of mental health problems. In an attempt to glean some sense of people’s feelings of social connection survey respondents in Phase Three of the study were asked to indicate if and how often they feel lonely. The pie chart below gives the results to the question and shows that out of a total of 1,025 people who answered the question, on the whole most people never feel lonely. However, there is a small but significant number (8%) of people who feel lonely ‘all the time’ or ‘most of the time’.

Stated levels of loneliness

2%6%

39%53%

All the timeMost the timeOnly sometimesNever

No of respondents 1025

Phase Three focus groups and surveys also illustrate the importance for people to have a positive connection with neighbours. The following is indicative of some of the responses we received from residents who completed surveys in Phase Three of the study.

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We have been fortunate in having long term good neighbours and this really goes a long way in any neighbourhood (Beckenham)

I have not had much time to explore the area but have friendly neighbours who are happy to help out (Newly relocated to Southern River)

The map below shows the incidence of community based service provision for mental health related problems in the Armadale Kelmscott Health Region. It indicates that the City of Gosnells local government area is of the highest areas of service use within the region. However, at a State level this is below average. The map is based on the post code areas of the Armadale-Kelmscott Health region (see Appendix 4 for specific City of Gosnells post code areas) and represents the number of 'Mental health' related community based occasions of service per 100,000 persons (1995 - 1999).

(Developed by Codde, J. Epidemiology & Analytical Services, Health Information Centre, HDWA (Last modified: 31

December 2000; printed: 12/12/01)

Counselling services: Whilst there are numerous counselling services operating in the City of Gosnells local government area many services across all sectors identify a shortage of:

• affordable counselling services

• culturally appropriate counselling services

• crisis counselling

• drop in centres for informal support

• culturally appropriate mental health workers in services

• a centrally located centre with the capacity to do outreach into the community

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Waiting lists are common with service providers report a range of 6 - 16 weeks. These waiting times cannot be seen as satisfactory when one considers people seeking counselling are often fragile and feeling vulnerable. This issue is particularly significant when trying to access out-of-hour services and services for youth.

Mental health and youth: Many services identify mental health is an import issue for young people in relation to emotional problems, self esteem and social isolation. This is indicative of wider findings from the Australian Institute of Health and Welfare First Report of Young People aged 12-24 where it was argued that ‘The major burden of disease for this age group is from mental disorders (clinically recognisable symptoms or behaviour associated with stress and interference with personal functions’ (1999: x).

In addition, that ‘suicide has not followed the declines seen for most other causes of death in this age group-suicide rates increased over the period 1979-1997, particularly for males’ (1999: x).

It was reported there is a shortage of mental health services for adolescents and children (supported by the waiting lists for counselling services) and that there are not enough in-patient beds to cater for the needs of younger clients.

Mental health of children: Several service providers identify that children are experiencing increasing mental health problems due to, stress, family problems, family separation, family dynamics of ‘blended families’, etc and that there is a lack of affordable or free counselling services and/or crisis care services to refer families and children too.

Health promotion: Services indicate there is a shortfall in more preventative work in terms of providing real, practical, social and economic support for families and children in the Gosnells Local Government area. They state counselling services should not stand alone as a panacea or total solution to the diversity of mental health problems. Concerns about mental health promotion are linked to wider social and economic policy.

As outlined in the introduction to this section the promotion of good mental health must be addressed in a holistic way and some of the identified underlying factors associated with mental health problems are addressed in many of the other sections of this report.

Postnatal depression: The participating service providers working with women state that postnatal depression is an issue for some women and the Gosnells Women Health Service and Armadale Child Health Nurses work together in relation to this issue. Women may also be cared for through the Armadale Health Service through general referrals from General Practitioners.

27 DRUG AND ALCOHOL USE AND MISUSE

Substance use (including alcohol) and misuse is a complex social issue and in many cases substance misuse cannot be isolated from the general social health of a community. As Palin and Beatty assert ‘mood-altering drugs have been used by just about every culture that has ever existed on this planet’ (2000: 11). They make the important point that ‘our attitudes to drug use are relative to the time and culture in which we live’ (Palin and Beatty, 2000: 12). However, professionals working in the drug and alcohol sector identify the greatest concern lies in what they term ‘excessive detrimental abuse’. This is associated with particular health and social problems, such as early childhood developmental issues, mental health problems, family violence and dietary issues. Problems that are made more complex by patterns of drug use that often involve multi drug use and the misuse of prescription drugs.

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For some people who use drugs it is possible to remain relatively healthy if they have the adequate financial support and material resources to care for themselves in terms of diet and health care. However, for those who are economically or otherwise disadvantaged who use drugs or alcohol excessively, or in ways that do not minimise harm, there can be significant health and social consequences.

The difficulty faced by policy makers and services is that drug use is often a hidden problem and that there is little agreement on how best to address the problems associated with drug misuse. This was highlighted by the 2001 Western Australian Community Drug Summit held in Perth. Debates extend to what should reasonably count as illicit drug use as opposed to legally sanctioned licit drug use. For example, some sections of the community accept Cannabis use is equivalent to alcohol use. Further, debate also surrounds treatment regimes and strategies incorporating both medical and non medical approaches, whether abstinence or harm reduction is the key, and so on (Lenton and Single, 1998).

The policy and service responses to drug and alcohol misuse incorporate a number of different treatment regimes and strategies at national, state and local levels. However, much of the direction in policy at a local level is informed by national and state developments. In Australia an evaluation of the National Drug Strategic Framework 1998-99 to 2002-03 describes the policy framework for reducing drug-related harm in Australia as incorporating a co-ordinated and integrated approach including the areas of law enforcement, criminal justice, health and education, community-based sector, business and industry, research institutions, local communities and individuals (Ministerial Council on Drug Strategy, 1998: 16). One of the major principles underpinning the National Drug Strategy is that of ‘a balanced approach’ (Ministerial Council on Drug Strategy, 1998: 17). This refers to seeking a balance ‘between supply-reduction, demand-reduction and harm reduction strategies, emphasising the need for integration of drug law enforcement and crime prevention into all health and other strategies at reducing drug related harm’ (Ministerial Council on Drug Strategy, 1998: 17). The evaluation notes, that whilst illicit drugs cause a great deal of concern to specific communities, the misuse of licit drugs is far more widespread and causes significant harm (Ministerial Council on Drug Strategy, 1998: 17). Others note the problems in defining such terms as ‘harm reduction’ stating that whilst abstinence-oriented strategies may be included under such definitions ‘the primary goal is the reduction of drug-related harm rather than drug use per se’ (Lenton; Single, 1998: 216).

A national study into Aboriginal and Torres Strait Islander substance misuse recently recommended the incorporation of a holistic approach in drug and alcohol misuse problems strategies. In particular the study suggests attention be paid to the issues associated with housing, transport, community development, non medical detoxification, counselling programs, clinical services – needle exchange, night patrols and sobering up shelters, crisis accommodation, refuges, regulation of supply of substance, community education and promotion programmes in relation to nutrition, substance misuse and injury and violence (Commonwealth Department of Health and Aged Care, 1999: 100).

This reflects the philosophy underpinning the Gosnells Community Health Needs Study which emphasises the social determinants affecting a range of health problems including that of drug and alcohol misuse.

The adoption of a multiple approach to drug and alcohol misuse has increasingly included ‘harm reduction’ strategies, such as needle exchange vans and health information campaigns on alcohol use and youth. Whilst parts of the community express concerns that these types of strategies encourage drug use, professionals working in the Drug and Alcohol Sector point out they are successful in reducing self harm, blood borne viruses and the likelihood of inappropriately discarded needles; this is backed up by statistics from the needle exchange service currently operating in the City of Gosnells local government area (see details below).

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The City of Gosnells has recently developed a policy on the collection and disposal of improperly discarded sharps in public places in response to such concerns. It aims to give advice to people who have been injured by improperly discarded sharps and to educate the public on how to safely dispose of sharps.

The City of Gosnells is also in partnership with the City of Armadale and the Drug and Alcohol Office in the Gosnells Armadale Alcohol Project (GAAP). This is a pilot programme to develop innovative and collaborative strategies aimed at addressing alcohol related health, crime and injury in the Gosnells and Armadale communities. The City has already developed an alcohol policy that outlines the key components for addressing alcohol issues and will involve a survey of alcohol licensees to gauge the level of knowledge and awareness of Licensing Acts and alcohol issues.

There are also a number of other strategies in place to address the complexity of drug and alcohol misuse. These include measures such as educational visits at schools, health promotion by school health nurses, night patrols, counselling, volunteer drug support and action groups (for example the Southern Districts Local Drug Action Group) who work closely with Kenwick Youth Centre. The issue of drug and alcohol misuse is an ongoing and entrenched health issue globally and whilst this may be seen as cause for concern it can also be viewed in a positive light in relation to knowledge about strategies and measures that may have some utility in the Western Australian context. Many of these such as ‘the Swiss experiment,’ in relation to solutions addressing heroin use are debated with vigour in the media and academic contexts (see Seidenberg, 1999). Similarly the Drug Summit made significant headway in terms of outlining major areas of concern and strategies to address drug problems although many service providers questioned the exclusion of alcohol from the debate. All of these issues are of course larger than the City of Gosnells to deal with in isolation, but certainly indicate the usefulness of more integrated approaches and the importance for open communication at the local level. The local area network meetings organised by the City of Gosnells is one such positive measure in this regard.

Service providers in the City of Gosnells local government area are funded through various government and church based organisations. Departments providing funding include the Department for Community Development, the Department of Health Western Australia, Department of Justice, Mission Australia and the Salvation Army. There are also various peak bodies that provide information and support to the community in relation to drug and alcohol use and misuse, these include, the Alcohol Advisory Council, Noongar Alcohol and Substance Abuse Services (NASAS), Community Drug Services Teams, the Aids Council WA and the Western Australian Network of Alcohol and other Drug Agencies (WANADA).

27.1 Outline of Services

Support and Counselling Services: The following services are available for people living in the City of Gosnells local government area:

• The Community Drug Services Team covers the entire South Eastern Corridor, including the City of Gosnells local government area. It provides counselling and social support to individuals and families and all age groups. The average age of clients is 25-35 years of age. Whilst they see people from a diversity of CALD backgrounds clients are predominantly from English speaking backgrounds and from working and middle class socioeconomic backgrounds. The service is currently addressing a recognised weakness in accessing Aboriginal people.

The team provides counselling through Wattle House and outreach services to the Department of Justice in Maddington. It also offers training and support to other local agencies that deal with people who have drug or alcohol problems and community initiatives that work in the area of drug and alcohol services.

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• Drug ARM WA provides counselling to people who have an addiction and family members living with someone with an addiction. It operates a ‘Street Van’ for outreach services and several youth based programmes including:

o Youth Skills Training for youth at risk between 15-18 years of age. This service is linked to the Department of Justice and is aimed at providing young people who are truanting and/or at risk with life skills.

o Time Out Centre provides overnight accommodation for up to 4 youth who are intoxicated or under the influence of drugs. It also has 2 beds allocated to a Supervised Bail Programme for youth.

Drug ARM also is a reference point tor the community for information about drug and alcohol issues. They also go into schools and run education programmes.

• WESTAN, based at Wattle House, is an Aboriginal voluntary managed organisation that works with Aboriginal youth at risk and who are truanting or using solvents. It was set up to respond to Aboriginal youth solvent abuse in the Gosnells/Maddington area.

Counselling and Support services are also available through numerous providers situated outside the City of Gosnells local government area and include:

• Next Step providing information, counselling and referral advice.

• Wesley Mission, HEARTH programme providing outreach to parents with drug and/or alcohol dependencies and to family members who need to learn how to live with family members who have an addiction.

Rehabilitation Services: Harry Hunter Rehabilitation Centre is located on the border of the City of Gosnells and Armadale local government areas. It is administered by the Salvation Army and caters for men and women who are experiencing difficulties with drug and alcohol abuse. The Centre offers counselling and rehabilitation services as well as residential accommodation. It works with Employment Plus to reintegrate clients into the workforce. Most clients are referred from outside the City of Gosnells local government area.

Rehabilitation and detoxification services available outside the City of Gosnells local government area include:

• Drug Arm has a rehabilitation centre situated in Geraldton

• Next Step has a residential centre

• YEERA is a youth residential centre in Carlisle managed by Mission Australia

• Bridge House is a detoxification centre managed by the Salvation Army in Highgate

Needle and Syringe Exchange Programme (NSEP): An exchange programme operates in the City of Gosnells local government area and is in its second year of operation. The main function of the programme is to help prevent the transmission of blood borne viruses (BBVs) such as HIV, hepatitis B and hepatitis C amongst people who choose to inject drugs. Needle exchanges are called a ‘primary harm reduction strategy’. There are many myths and misconceptions about needle and syringe exchange programmes in the community.

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However, the harm reduction approach of needle and syringe exchange programmes operate through a health promotion philosophy that acknowledges some people engage in behaviour that has the potential to damage individual and community health. While not condoning such behaviours, harm reduction strategies adopt a non-judgmental approach to encourage people to adopt safer behaviour to minimise damage to their health and help to improve the health and wellbeing of the community.

Needle and syringe programmes are also in a unique position to make contact with and advise people using drugs, including acting as a first step to treatment and counselling when requested or appropriate. Needle and syringe exchange programmes also offer a range of other important services to drug injectors including the provision of swabs, sterile water, ‘sharps ’containers for the safe disposal of used equipment (a vital aspect in reducing the risk of harm to the wider community), referral to treatment and counselling services, primary health care, counselling and education, information and educational material on issues such as hepatitis, blood borne diseases, nutrition, appropriate disposal of sharps, and the importance of hygiene.

The provision of needle and syringe exchange programmes is supported by the Australian National Council on Drugs and is recommended as a strategy for harm reduction for the individual injecting drug user and the wider community (Needle and Syringe Programs. A Position Paper, 2002). Results from the first year of operation of the service in the City of Gosnells local government area are very positive with an average of 93.25% needle return rate and an increase in the number of people accessing the service.

The table below shows the client statistics and needle return rates for the 2001 year of operation of the needle and syringe programme in the City of Gosnells local government area. These statistics have been provided by the Needle Exchange Service and are previously unpublished.

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Month April May June July Aug Sept Oct Nov Dec Jan Feb Total

Total Returns 366 1306 2490 2260 2521 1919 4452 5156 4982 5226 4344 35022

Total Distributed 386 1206 2460 2360 2521 2653 4507 5518 5502 6028 4416 37557

Percentage 95% 108% 101% 96% 100% 72% 99% 93% 91% 87% 98% 93.25%

Total No Clients 5 10 27 19 41 36 40 81 49 64 46 418

Male 2 6 19 12 19 23 28 59 30 43 34 275

Female 3 4 8 7 22 13 12 22 19 21 12 143

<16yrs 0 0 0 0 0 0 0 3 0 0 0 3

16-25yrs 4 5 9 6 13 17 15 46 7 13 10 145

26-40yrs 1 5 17 12 25 19 20 28 32 46 31 236

>40yrs 0 0 1 1 3 0 5 4 10 5 5 34

Indigenous 0 0 0 0 0 0 0 4 4 0 0 8

Total Info/Ed 0 1 1 1 18 5 2 15 26 24 36 129

Timetables 2 6 5 3 5 3 5 5 5 6 2 47

Total Referral 2 0 4 1 0 0 0 0 0 0 0 7

Data supplied by the NESP for the year 2001

27.2 Findings

Alcohol, Drug use and solvent abuse: Many of the participating service providers across sectors report there is a significant level of drug and alcohol use within the community. Services identify men as a special needs group particularly in relation to alcohol and its impact of family relationships. They identify various factors that have an impact on drug and alcohol use including social isolation, relationship/family breakdown, lack of family support, mental health issues, sole parents who are locked into care giving roles and unable to pursue career, work or education opportunities. Generally it was felt that people who have stability in their lives and good mental health are less likely to use excessive amounts of drugs. A major drug service working in the region identifies the most commonly used drugs in the City of Gosnells local government area to be Amphetamines, alcohol and cannabis. Other services, particularly those working with youth, have also identified solvent misuse as a major problem.

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The map below represents the number of 'Other drugs' related hospitalisations per 100,000 persons between 1996 and 2000. It indicates that within the Armadale-Kelmscott Health Region that the City of Gosnells local government area, along with the City of Armadale local government area, has the highest incidence of illicit drug use within the immediate region. However, these rates of illicit drug use are still below the Western Australian average, and compare favourably with other Perth metropolitan areas.

The map is based on the post code areas of the Armadale-Kelmscott Health region (see Appendix 4 for the City of Gosnells local government area post codes).

(Developed by Codde, J. Epidemiology & Analytical Services, Health Information Centre, HDWA (Last modified: 31 December 2000; printed: 12/12/01)

Survey findings from Phase Three of the study reflect there is a degree of community disruption through the misuse of alcohol and other drugs with several indicating that there is open misuse of alcohol among youth, often in parks and public places; as illustrated by the following quotes from surveys:

Antisocial behaviour at night; drinking, swearing, broken bottles, urinating from underage youths (girls and boys). We are on a street with a walkway leading to Forest Lakes Tavern (Thornlie)

The only problem we encounter are drunken youths on Fri and Sat nights after they have been to Lakers Tavern in Forest Lakes. They bang on signs and throw their beer bottles on the lawns (Thornlie)

Policing of alcohol use in Pioneer Park, so public feel safe to use it…lovely area (Martin)

In a focus group with youth, substance misuse was raised as a concern that young people have in relation to their friends. All of the participants stated that they knew someone with a substance misuse problem.

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Service providers and Phase Three survey findings link the lack of affordable recreational options for youth with the level of alcohol and drug use among youth in the local area (for full findings on youth and leisure see section 17).

A mother, who is concerned about her own children’s drinking patterns, responded to a question about leisure that her children were often found

Drinking and hanging around, with mates at the park (Gosnells)

Further anecdotal evidence suggests that whilst wide spread use among younger primary school age groups is low it is still present. According to several participating service providers illicit drugs are easily accessible, even to the very young, and that inappropriately discarded needles are not uncommon around parks and school grounds. This is confirmed by respondents to the survey in Phase Three of the study who relate:

…went to Carols by Candlelight at the amphitheatre and experienced anti social behaviour and syringes in the sandpit/toilet area (Gosnells)

Parks in area don’t attract kids – rather junkies (Maddington)

…targeting the drug dealers in the area, maybe the youth might be more interested in sports or recreational facilities (Maddington)

The City of Gosnells policy on the collection and disposal of improperly discarded sharps aims to provide people with the necessary information to protect the general public from the risks associated with inappropriately discarded sharps but is not a preventative measure. The NSEP works more to prevent the inappropriate discarding of needles.

Note: Many of the contributing factors to the misuse of drugs and alcohol relate to complex social and family issues as outlined above, many of which are addressed in other sections of the report.

Lack of locally based services: Participating service providers report that people generally must travel outside the area to Armadale or Perth City if they wish to access support, counselling, detoxification or rehabilitation services. Harry Hunter was named by several services as a good comprehensive rehabilitation programme but a key informant from Harry Hunter informed us that very few people from the City of Gosnells local government area are referred to the service. A focus group with youth also identified that there is a lack of local rehabilitation and referral places for youth in the area.

There are some outreach and counselling services in the City of Gosnells local government area, but it was identified that there is a need for a service that incorporates a drop in centre with counselling services and outreach services attached that accommodates youth and adults and involves Aboriginal Services. It was also felt there needed to be a locally based detoxification centre for youth.

A number of services made positive comments in relation to WESTAN; the only organisation that responds specifically to solvent abuse and Aboriginal youth. It was noted that the organisation was managed by volunteers and required further resources and ongoing support to enable it to respond adequately to demand.

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Retail registry of solvents distributors: Some services believe a registry of retailers selling solvents would assist in policing their sale. It is believed that it would allow more intensive and ongoing follow up with the retailers in the City of Gosnells local government area. The City of Gosnells presently has a supporting role in a local initiative that works with children and youth who use solvents.

Whilst a registry of retailers is one measure there are complicating factors which might limit its usefulness in regulating the sale of solvents. In many instances the sales assistants are young, inexperienced and may not feel empowered to refuse the sale of solvents to a customer. This kind of regulatory response would need to be backed up with considerable preventative strategies that work with communities to educate parents and young people about the misuse of solvents.

A recent review by the National Drug Research Institute (NDRI) on Indigenous Drug and Alcohol Projects 1999-2000 and commissioned by the Australian National Council on Drugs (ANCD) identify that there is a greater need to emphasise prevention and health promotion strategies, especially those contributing towards the creation of constructive leisure and employment options for young Indigenous people (Gray et al., 2002).

Accessible and accurate information: Service providers working with people who use drugs state that it is difficult for people using drugs to obtain access to well informed, appropriate health information. As service providers point out, judgemental attitudes and recriminations only create barriers and stop people obtaining information necessary to their health and the health of their families and the wider community.

Mental health: Several participating services report that mental health issues are an important underlying factor in drug use. One service provider refers to some drug use as a form of ‘self medication’. Mental health was also raised in relation to self esteem issues and the need to empower people to feel in control of their lives. The following response to the survey in Phase Three reflects the complexities surrounding drug use and ‘spoiled identity’ and the struggle to reconstruct one’s life in the face of discriminatory community attitudes which disempower and undermine self confidence (Goffman, 1959):

…Maybe looking at people in different ways. Not judging everyone the same. We all have problems. I am a victim myself of childhood trauma and as a result have had a drug problem. I am trying to deal with this but most people will discriminate you as being no good… I am very sad to experience a feeling of not being treated fair in the community. Doesn’t feel like [the community] is giving people a chance to try and overcome a drug addiction and give them a chance of success (Thornlie)

Youth services: Findings from focus groups and service providers identify a lack of preventative programmes directed at youth who are truanting and at risk of offending and participating in harmful behaviours. Because of a dependence on Department of Justice funding, programmes for youth are reliant upon the priorities set by the Ministry. There was some discrepancy between different services and groups about the age range that was most at risk. Some identified that the biggest gap was for those in the 13-15 year age groups, however, others indicated that it is in fact the 10-12 year olds who are most neglected in relation to preventative programmes, including leisure options and programmes directed toward reducing truancy. Service providers and focus groups highlight that to wait until youth have come to the notice of the justice system is too late. Directing programmes at younger age groups was considered by many as a more responsive and effective strategy.

Aboriginal drug services: Several services working in Drug and Alcohol Services as well as Health Services highlight drug and alcohol use among the Indigenous community of the City of Gosnells local government area as a significant problem. They indicate a need for more locally based services managed by and targeted toward Aboriginal people or for an increase in the presence of Aboriginal workers in ‘mainstream’ services.

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This finding is backed up by service providers in their admission that there are low numbers of Aboriginal people accessing ‘mainstream’ drug and alcohol services. The need for more Aboriginal workers is widely recognised (see the Review of the Commonwealth’s Aboriginal and Torres Strait Islander Substance Misuse Program: Final Report, 1999; Gray et al., 2002) and is a major recommendation coming out of the Drug Summit with the proposal that all Community Drug Services Teams have Aboriginal workers on staff. One major service provider recounted that having an Aboriginal worker in the team has noticeably improved networks and communication with the Aboriginal community. Those services that do exist in the City of Gosnells local government area were reported to be overloaded and under resourced.

28 ENVIRONMENTAL HEALTH

Environmental health is an important but often overlooked issue when discussing health and community wellbeing. However, as pointed out in the National Environmental Health Strategy (1999) environmental health is indeed the ‘cornerstone of public health’ and ‘provides much of the basis for modern society’ (1999: 1). Environmental health covers a broad range of issues relating to factors in the environment which can have a harmful effect on health and quality of life including, basic issues about where people live, what they eat and water quality, to more complex problems of waste management, agricultural practices, pest control, and sound pollution. Environmental health also faces broader global challenges due to increased levels of air, water and soil contamination, chemical pollution and global climate changes (see, National Environmental Health Strategy Commonwealth of Australia, 1999). It thus involves questions of public health and health promotion in relation to respiratory and infectious diseases and is a significant part of local government management.

Environmental health comes under the auspice of the Environmental Health Branch of the Department of Health. The Environmental Health Branch has a regulatory function and administers the Health Act, the Poisons Act, the Radiation Safety Act and a number of other Acts and associated Regulations. It works in partnership with local government by providing expert advice in relation to the safety of food, meat, radiation, drinking and recreational water, pesticide use, mosquito-borne disease control, drugs, poisons, therapeutic goods, toxic substances, and wastewater management.

Many environmental factors that could pose a risk to health are monitored at the local level through local government and include:

• waste disposal

• water and air pollution

• food contamination

• wastewater disposal

• mosquito and other insect control

Various public and environmental health services are provided by Environmental Health Officers employed by local government to prevent the occurrence and spread of disease. Their role is to promote good health, hygiene and environmental practices and to regulate, monitor and ensure compliance with laws and regulations governing public health and environmental management. They are also authorised persons under the provisions of the Environmental Protection Act 1986 and the Environmental Protection (Noise) Regulations 1997. Further, they may also be involved with planning assessment and building control.

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Recent years have seen an increase or resurgence in the occurrence of infectious diseases that were previously thought to be on the decline in developed countries. This trend indicates a need to remain mindful of the role that Environmental Health Officers play in the community. At a national level, it has been recognised that the fragmentation in the management of environmental health issues has meant that there has been a lack of coordinated programmes and management with duplication and reduced awareness being the result. Thus, the National Environmental Health Strategy has launched the National Environmental Health Council as a peak advisory body (National Environmental Health Strategy Commonwealth of Australia, 1999).

As indicated by the findings in this study the importance of health promotion should not be overlooked. In conjunction with the Commonwealth Department of Health and Department of Health, local government is also taking an increasing role in health promotion. However, the City of Gosnells role is generally limited to supporting campaigns, such as Quit Week, Drug Awareness, Food Safety, Smoking, Exercise, Nutrition, Heart Awareness, Alcohol and a variety of other health issues relating to healthy living and lifestyle.

28.1 Outline of Services

The City of Gosnells Health Services Branch lies within the City’s Regulatory Services Directorate. It has a regulatory function and administers a diverse range of Legislation. The primary function of the Health Services Branch involves the administration of the Health Act 1911 and covers a broad range of environmental and public health issues. It has developed a Health Plan with the aim of promoting high standards of health, social and medical services. The Health Services Branch has 12 programme areas covering Administration; Health Care Services; Safe water; Housing Buildings and Accommodation; Disease Control; Vector and Pest Control; Waste Water Disposal; Health Promotion; Alcohol and other Drugs; Pollution Control and Nuisances; Enforcement, General Surveillance and Other.

For further details see the City of Gosnells Health Services Branch Annual Report for the 2001/2002 financial year.

Waste Management: Waste Management is under the care and control of the City of Gosnells Infrastructure Directorate - Waste Management Branch. A weekly rubbish collection is provided by the Council and a kerbside recycling service is provided by Cleanaway. Bins are collected by robotic arm vehicles. The City of Gosnells no longer operates a waste disposal site and ratepayers are not provided with free or discount passes to access alternative waste disposal sites.

The City of Gosnells carries out three separate kerbside bulk rubbish collections per year. One is for the collection of general ‘junk’ and the other two are garden waste collections. These collections are advertised in the local newspapers and leaflets are available at the Administration Centre approximately two weeks prior to commencement. Residents are also informed of the collection date through leaflets which are delivered approximately 10 days before the collection starts in their specific area.

28.2 Findings

Rubbish and bulk refuse disposal: Phase Three survey findings show that the residents feel strongly about the lack of free or affordable access to tip sites and the level of frequency of green-waste collections. Many respondents made direct comments on this matter when asked about the availability of services and quality of life in the local area. The quotes below are a small sample of those comments and capture the depth of feelings surrounding this issue:

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Increase frequency of rubbish collection service! i.e. tree branches etc. – need more often, not ONCE EVERY 18 MONTHS! Other councils are more frequent in this area (Thornlie)

As rate payers we do not enjoy the same service as in the past e.g. general rubbish and green-waste curb side pick-ups. These are few and far between. For people to hire bins privately to dispose of general rubbish or green waste is very costly. Tidy cleaner yards would make for a better environment. Council could have free mulch for streetscape and save (Maddington)

No landfill site in City of Gosnells is just not good enough…. residents are expected to travel to neighbouring tips at full cost. At least some entry passes should be included in price of RATES (Maddington)

Disappointed at lack of regularity of green-waste collections (14 months between most recent service and time before) and junk collection (2 years since last one!) (Beckenham)

The availability of a local rubbish disposal site would be good (Kenwick)

… Once the Kelvin road tip was closed we had to pay exorbitant tip fees to the recycle station that subsequently closed. I’m not aware of any facility now open to me in our district (Thornlie)

No recycling centre – need one – very poor performance from Gosnells Shire (Langford)

The problem of rubbish was also raised in Phase Three surveys in more general terms:

I get perturbed with the amount of rubbish left lying around in the streets… However, there is a general lack of rubbish bins which I assume contributes to rubbish being dropped in the first place (Gosnells)

More general clean up services - how else do we expect to keep a clean neighbourhood (Maddington)

People dump rubbish in drains/ditches (Orange Grove)

… more attention to cleaning of glass, debris and garbage in public places (Maddington)

The volume of these responses gives some indication about how important having pleasant, clean and tidy surroundings is to people’s sense of satisfaction and feelings of pride about where they live. It can also be significant in creating a sense of community as two respondents from Phase Three surveys suggest:

A community clean-up programme may help people feel more a part of the community (Kenwick)

There should be more council clean-ups i.e. verge pick-ups per year. It would encourage people to take more pride in their area (also… we pay high enough rates to cover this!)

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Waste disposal is an increasing challenge in the modern world at the international, national and local level. In highly populated metropolitan areas where building developments are occurring and land is at a premium there is a shrinking amount of appropriate landfill space. Local governments face a real difficulty in addressing overall sustainable use of resources, whilst meeting community expectations and patterns of consumption. It generally acknowledged this is a wider problem and that there is no easy solution.

Noise pollution: Surveys identify that the level of noise in residential areas is considered stressful for many people. Whilst barking from dogs was referred to several times, different types of noises were cited as problems and were often linked with feelings of safety, as the following illustrate:

… the locality attracts an anti-social segment that persistently cause noise and disruption in the form of excessive speed on the road and thoughtless use of motor vehicles. After dark there is a considerable amount of loutish behaviour which presents a constant sense of threat (Gosnells)

… the regular fireworks that are set off during the nigh greatly distressing my dog (Gosnells)

Noise control measure from the currently being constructed Roe Highway were/are not even contemplated for the rural eastern side of the Hwy (Kenwick)

Irritating/loud noise from gun club at weekends (Orange Grove)

Too many cats running around all night long. Industrial Noise (Kenwick)

The home areas in some places are workshops for wrecks and old cars and an eye sore as well as noisy and we’re very blessed to have one next door (Maddington)

… Roe H’way and the airport noise… the planned runway will bring more planes and noise over Beckenham and Kenwick (Beckenham)

These findings are in line with the City of Gosnells 2000/01 Annual Health Report which states that noise is the most common pollution complaint received by the Council’s Health Services Branch. During 2000 -2001 the Health Branch received a total number of 255 complaints/service requests (an increase of 19%) and these represent over 39% of the total number of complaints/service requests received by the City Environmental Health Officers (City of Gosnells, Health Services Branch, Annual Health Report 2001/02).

The City has a well developed protocol for complaints however the findings suggest that residents may also have unrealistic expectations about the capacity of the local Council to control noise violations and the regulatory limits in which they operate regarding what is considered acceptable noise levels associated with modern suburban life.

(for full findings on speeding vehicles see the section on Built and Natural Environment 13.)

Relationship between environmental health and other community issues: Services report concerns about people’s health in relation to homelessness, financial constraints and non-payment of utilities resulting in overcrowding, interrupted water supply and lack of power. Whilst service providers do not connect these explicitly to environmental health issues these issues contribute toward lack of sanitation and personal and household hygiene. Clearly they raise concerns about hygiene, food contamination and communicable diseases.

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Safety: Some service providers and several survey respondent express concern about inappropriate needle and sharps disposal in public areas especially parks (for full findings in relation to inappropriate needle disposal see section 27).