7 November 2022
Select Committee into Child Development Services
Legislative Council Committee Office
Parliament House
4 Harvest Terrace
West Perth WA 6005
Email: sccds@parliament.wa.gov.au
Dear Select Committee into Child Development Services,
RE: Inquiry into child development services Western Australia
1. Derbarl Yerrigan Health Services Aboriginal Corporation
Derbarl Yerrigan Health Service (Derbarl) welcomes this opportunity to provide comment to the Inquiry into child development services on behalf of our service, health professionals, families and children.
In accordance with the United Nations Convention on the rights of a child, children have the right to good quality health care, clean water, nutritious food and a clean environment so that they will stay healthy.
Derbarl is concerned the rights of children, particularly those with neurodevelopmental disability, are not being met in Western Australia (WA) due to a failure to address the social and economic determinant of health, systemic racism and child development systems ill-equipped and insufficiently resourced to meet the needs of our most vulnerable children.
Derbarl is the largest Aboriginal Community Controlled Health Service in Western Australia providing culturally responsive primary health care services to over 20,000 Aboriginal patients throughout the Perth metropolitan area including 5,480 children and young people. Our service also provide care to 5000 clients from the regional and remote areas who visiting Perth.
2. The role of child development services on a child’s overall development, health and well-being
Aboriginal children are disproportionately represented in our health care system for many preventable childhood illnesses.
From a developmental lens, it is well documented in the Australian Early Development Census (AEDC) data that Aboriginal children have high rates of developmental vulnerability.
For Western Australian, Aboriginal children remain below the national performance rate. AEDC data in 2021 for WA, showed only 31.3 per cent of Aboriginal children were assessed as developmentally on-track across all five domains of child development.
For girls this figure was 37.8 per cent developmentally on track. For boys it is 24.9 per cent on track at the time they commence full time schooling. The rates are even worse in lower socio-economic areas, which includes the locations of many of the families that Derbarl services.
The AEDC data highlight the important deficits in health, education and social systems to provide timely support for Aboriginal families while children are young. The lack of response to developmental vulnerabilities whilst children are very young increases the risk of school disengagement, the exacerbation of complex health problems, health-risk behaviours and high rates of premature death.
Adolescents detained within the criminal justice system are affected by complex health problems, including high rates of cognitive impairment and neuro-disability. The life trajectories of many of these young people are characterised by entrenched poverty, disadvantage and instability.
WA incarcerates proportionately more Aboriginal children than any other State in Australia with 79% of detainees Aboriginal. 89% of the children incarcerated have neurodevelopmental disability (Banksia Hill Study, Telethon Kids Institute) and require wrap around support, treatment plans, and multidisciplinary care in a culturally safe environment. Early intervention, diagnosis and treatment could prevent incarceration to avoid the horrifying consequences of children incarcerated in Banksia and Casuarina today.
3. The delivery of child development services in both metropolitan and regional Western Australia, including paediatric and allied health services.
3.1 Paediatric Services in Metropolitan Perth
At present, health professionals in Perth who need to refer an Aboriginal child for State Paediatric care must complete two referral forms to access a State Paediatrician via the Child Adolescent Health Service (CAHS). These two services are the:
- Koorliny Moort Team (the CAHS Aboriginal Paediatric service based at Perth Children’s Hospital) and
- the Child Development Service (CDS)
Koorliny Moort have identified their scope as a navigator service into the Child Development Service. KM will not assess referrals that are for children to see a Paediatrician unless there is proof that a CDS referral has also been submitted.
Whilst Derbarl values the Koorliny Moort service, we are keen to work with their service to develop a model of care that works with the strengths of Aboriginal community control, embedded within primary health care, to improve efficiency and coordination of care.
Derbarl’s GPs have the capacity to deliver clinics alongside specialist paediatricians to reduce wait times, improve communication, and improve follow-up for patients. Community consultation about an improved service model design with Derbarl leading under an Aboriginal lens is welcomed.
Siloes have developed throughout Perth specialist diagnostic services and it has become increasingly difficult to navigate service provider provisions and necessary and appropriate referrals.
A declined referral does not result in the referral being redirected to the most appropriate service; it results in a child not receiving necessary care. It is an injustice to our children that we have found our patients are being completely missed and slipping through the multiple gaps in the system resulting in significant delay at the onset of school.
3.2 Child Allied Health
The State Government currently provide no investment into allied health services for children that access care at Derbarl. Derbarl do not have funded speech therapists, occupational therapists, developmental social workers or physiotherapists.
Currently, children requiring allied health services and support are guided by State Government options, which are to refer Aboriginal children to the CDS Allied Health Team and the CDS Aboriginal Health Team. These teams are focused on the early intervention space 0 – 5 years and find it difficult to continue providing services to children over 5 years. There are also significant wait times to gain access to these services.
There is a significant gap in care as Aboriginal children and their families can present late with health concerns and developmental concerns; and consequently, it is common for Aboriginal children to miss the opportunity of early intervention/s.
The CDS Aboriginal Health Team have provided welcomed support through their 9 clinics across Perth. However, eligibly is up to 4 years 11 months. Children five years and over and ineligible to access support. The CDS Aboriginal health team have 1.0 Full time equivalent (FTE) Speech pathology position and 0.6 FTE Occupational Therapy position. Their role is more transdisciplinary in order to support CDS referrals and Service Plans for families and developmental support until families are picked up by CDS and/or WANSLEA.
Derbarl sees many children who present late with their developmental concerns. It is well evidence and concurrent with our own experience, that the 0-5 years is a priority age group. Derbarl has great concern for our families where the CDS is not able to provide ongoing therapy for children who are 5 years and above. Many of our families do not have the means to afford private services or do not qualify for NDIS services for ongoing therapy (or have missed the opportunity to be referred to the NDIS early intervention service before the cut off at 7 years of age).
3.3 Financial barriers to families
With Derbarl’s experience in the primary health care space, the high cost of private child development support services is a barrier to many Aboriginal families across Perth. As mentioned above, many of our Aboriginal families do not access many private Paediatric or Allied health services or where there is an out-of-pocket cost involved. Financial hardship is faced by most of the clients we see. Derbarl Services are free to our patients (recovered through MBS claiming), hence, the nature of our clientele is skewed in seeing the most marginalised Aboriginal people.
Our clients’ poor economic circumstances limit GP options for private specialist referrals as there are very few service providers that bulk bill under Medicare or those that charge a small gap fee. If a GP sets up a GP management plan and Team Care Arrangement for Allied Health Services (or another option is an Aboriginal Child Health Check for Medicare Allied Health Services), many of our families do not have the means to fund out of pocket costs to access these services.
3.4 ADHD under the CDS
Currently there is no transition service pathway in Perth to place adolescents into adult psychiatry. Patients are falling through gaps as there is no state funded psychiatry services to enable our young people to access psychiatry services. Many of our families are not able to afford private psychiatry.
Derbarl GPs are able to co-prescribe ADHD medication which assists our current Paediatric model however the challenge is faced when these young people turn 16 and there being no pathway for psychiatric specialist care to transition these young people.
3.5 National Disability Insurance Scheme (NDIS)
There are two major challenges regarding the NDIS for Aboriginal families accessing services at Derbarl:
- a) Access into the NDIS - Many Aboriginal families are not aware how to apply for NDIS packages and services and are not aware that children under the age of seven may qualify for early intervention Support.
- b) Utilisation of NDIS packages - If Aboriginal clients attending Derbarl have received a NDIS package, they are not utilising the services to their best capacity. Derbarl has many families needing navigation support and coordination to help access NDIS services to the full capacity of their plan.
The Kimberley Aboriginal Medical Services (KAMS) NDIS trial of early intervention access to allied health services for children under the age of seven is a model that would benefit Derbarl and the Aboriginal children and families we serve.
3.6 Child Protection -Department of Communities
Sadly, given the number of Aboriginal children in the care of the Department of Communities, are our patients. The Department of Communities relies on our service to provide health assessments and to assist their primary health care needs including referrals into the right health services to assist the acute and complex health needs of the child/young person.
Derbarl requests the Department of Communities to show greater transparency if a child under their care has medical funding allocated to them. This will enable Derbarl clinicians to know if private Paediatric, allied health or psychological providers may be utilised so to avoid lengthy waits under the CDS or CAMHS. Derbarl recently welcomed State investment under the Health Navigator Trial to assist with running our Paediatric service for 2 years. The issue we will continue to have is a pathway through which developmental services can be accessed.
4. The role of specialist medical colleges, universities, and other training bodies in establishing sufficient workforce pathways
Derbarl is usually the first port of call for Aboriginal families that enter the Perth health system through the primary care pathway. Families feel culturally safe and secure in accessing our services including our Maternal and Child health team. Our service is an established trusted service in Perth for almost 50 years and a service where our families feel culturally safe with no judgement and no wrong door philosophy.
Derbarl strongly supports the formation of workplace development pipelines to increase capacity of General Practitioners, Child Health Nurses and Aboriginal Health Practitioners. Derbarl strongly believes investment in training from Medical School through to training colleges will increase the number practitioners both competent clinically but also culturally safe.
Derbarl is interested to work with the Child and Adolescent Health Services and GP Colleges to increase child health training for Paediatrics and GP Child Health. We also welcome other training specialties like child allied health, psychology, child health nursing and specific Aboriginal Health Practitioner training in child health.
5. Opportunities to increase engagement in the primary care sector including improved collaboration across both government and non-government child development services including Aboriginal Community Controlled Organisations;
Derbarl provides integrative and holistic health care to children from birth through to 18 years of age. Under an Aboriginal lens, we have designed our own Paediatric service model (through cocktail funding) anchoring a small team within a primary care model to deliver culturally appropriate care to children. This model includes the services of a private General Paediatrician (originally funded through Rural Health West for 3 hours a month + some recent expanded funding from WA Health); a Developmental Paediatrician (self-funded/philanthropy); 2 Aboriginal General Practitioners (GPs) and a Paediatric nurse (funded through Telethon Kids Institute). Derbarl also has a visiting Ear Nose and Throat Surgeon (funded through Rural Health West), an audiology service (funded through Hearing Australia) a paediatric respiratory specialist (philanthropy/ research) and a paediatric dermatologist (philanthropy/ research). Derbarl has a small amount of funding to support the employment of child health nurses.
Derbarl has designed a successful case management model. The attendance rate for our paediatric clinics is 98%, demonstrating a culturally safe and efficient service unmatched by CDS or Koorliny Moort. The success of the Derbarl model is based on a strong working relationship with families driven by a specialised paediatric nurse who works closely with families to coordinate their appointments and follow-up care. Our service provides a culturally safe place for our children and families to come. We also have Aboriginal GPs and Aboriginal Health Practitioners who address the primary health care needs of our children and their other family members. Derbarl is continuing to work hard on this successful model incorporating the strengths of primary health care with specialised services.
Derbarl is now running a parallel GP clinic run alongside the Paediatrician. This model gives Derbarl the ability to provide holistic care to families by offering Aboriginal health checks in coordination with their Paediatric appointment. This allows for referrals to be made for allied health or other supportive services on the same day. It also allows our families to address other primary health care concerns such as health lifestyles and immunisations. Our GPs can co-prescribe for conditions including ADHD and follow up with the families, while being supported by the paediatrician through shared care. This allows the Paediatrician to be focus on new assessments and complex clients, improving clinic efficiency and GP/specialist collaboration.
There is future potential to grow this model and to embed allied health services and mental health services within Derbarl. Derbarl could incorporate Speech therapy, Occupational therapy, clinical psychology and a Developmental Social Worker into the team. Derbarl welcomes any assistance from the State or the Federal Government to work with us in designing and funding this model of care for Aboriginal families under Aboriginal community control.
6. Other government child development service models and programs operating outside of Western Australia and the applicability of those programs to the State.
6.1 Providing a culturally Safe Service results in better attendance rates
Derbarl’s unique strength is its connection with the Noongar Aboriginal community across Perth metro. We are a trusted established service that employs a large Aboriginal workforce that is the strength of our service. Derbarl has found better success working with families who have had their Child Development Service referral closed by the CDS due to not being contactable or due to non-attendance.
Derbarl’s success with its own Paediatric attendance rates is due to a close working relationship with have with families and our ability to arrange appointments, facilitate referrals, and assisting to help families to understand their child. Our service also addresses transport and other barriers to access to services. We also work closely with families to ensure they understand their child’s diagnosis and management plans in a culturally safe and respectful manner.
Under the CDS arrangement, appointments are allocated to families by letter. There is a strict DNA policy of two Did Not Attends (DNAs) which result in a discharge from service or a discharge if a family is not contactable. The process when clients are not able to be contacted needs to be improved by the CDS such as for the CDS to employ Aboriginal staff, do home visits with an Aboriginal Liaison Officer or if the family are not contactable via phone or post to develop a more inclusive arrangements to collaborative and engage with families.
Some families have expressed interest that they would prefer to have their referral changed from CAHS Koorliny Moort or Child Development Service into the Derbarl paediatric service. Regrettably, due to limited funding and a growing wait list for our Paediatricians, Derbarl is unable to accommodate these requests. We do our best when an appointment become available to respond to families that are not engaging with either of the CAHS Paediatric services (CDS or KM). If Derbarl was provided with adequate funding to expand into a comprehensive service, many families and children would receive integrated care.
Since March 2022, Derbarl initiated a fortnightly Developmental clinic pilot with another Developmental Paediatrician through philanthropy. This service is planned to continue into mid-2023. Under this model, children are assessed and then transitioned into the Child Development Service for ongoing care for long term case management. Families who attend Derbarl have welcomed this service. The pilot is enabling many complex children to have their developmental assessments including Griffiths assessments completed before transitioning into the CDS.
6.2 Looking abroad: Integrated models of care to improve Paediatric access problems
An integrated model of care trial running across Victoria and New South Wales “Strengthening Care for Children” (funded by the National Health and Medical Research Council with the Murdoch Children’s Research Institute) are model for exploration between Derbarl and CAHS. This pilot has a Paediatrician placed in a general practice once a week for half a day where they see children together with the GP. Monthly case discussions are run so that the GPs can upskill and be more confident in their care for children in paediatrics. The project aims to strengthen the paediatric care skills of GPs; increase the knowledge of child health and management in general practice and reduce the need for referrals to hospital services. For further information please see the following links:
- RACGP - Paediatricians float solutions for deteriorating access problems
- Strengthening Care for Children Project - North Western Melbourne Primary Health Network (nwmphn.org.au)
7. Conclusions and Recommendations
Derbarl welcomes a future vision of designing a model of family and child health excellence for Aboriginal Children in Perth in collaboration with the State Commitment aimed at enabling access to Child Development Services in the State. Derbarl aims to develop a holistic model of care centred within the strengths of primary health care to offer Paediatric services, allied health services as well as mental health services providing trauma informed care in a culturally appropriate environment.
Derbarl makes the following recommendations to the Inquiry:
RECOMMENDATION 1: The Child and Adolescent Health Service (CAHS) to have one referral form for Aboriginal children.
RECOMMENDATION 2: CAHS to review the Koorliny Moort Paediatric model and request CAHS to co-design a model of care in partnership with Derbarl and the Aboriginal community of Perth through formal consultation.
RECOMMENTATION 3: The Department of Communities Child Protection Teams to better inform the Derbarl Yerrigan Health Service when children have State funding allocated to allow referrals to private providers. This will ensure that the most vulnerable children with developmental concerns are not negatively impacted by delays in accessing diagnostic services as well as assisting with timely therapy interventions.
RECOMMENDATION 4: That the WA State Government facilitate the Derbarl Yerrigan Health Service to work with CAHS Paediatrics and GP Colleges to provide training and supervision to grow a culturally competent workforce that has had clinical time and experience working in an Aboriginal Community Controlled Health Organisation.
RECOMMENDATION 5: That the WA State Government provide funding to embed Allied health services for Aboriginal children into the Derbarl Yerrigan Health Service.
RECOMMENDATION 6: To expand options for services for Aboriginal children with developmental needs above the age of 5 years, and to review transition pathways for adolescents as they move into adult-based care.
RECOMMENDATION 7: The State and Federal Government to review the NDIS Early Intervention Funding and to optimise access and support for eligible Aboriginal children in Perth
RECOMMENDATION 8: For the CDS and the Derbarl Yerrigan Health Service to be better resourced to assist patients attend appointments and to follow up on children who did not attend. Resourcing must include employment of culturally appropriate staff to work with families to both educate about their conditions and engage them with the system.
RECOMMENDATION 9: The State Government to invest in the Derbarl Yerrigan Health Service Paediatric model of care. This includes the provision of sustainable funding for:
- Paediatrician
- Developmental Paediatrician
- Allied health services including speech therapists, occupational therapists, physiotherapists
- Social Workers including Developmental Social Worker
- Child clinical psychologists and neuropsychologist
- Child-health nurses and Midwives
- Aboriginal Health Practitioners and Aboriginal Liaison officers
- Family support Officers
- Administration support
RECOMMENDATION 10: All incarcerated children and young people require a culturally appropriate health assessment and care plan immediately. The Derbarl Yerrigan Health Service, with proper resourcing, is ready and able to provide culturally appropriate specialised health care to ensure all Aboriginal detainees are not at risk of self-harm, or suicide, and a trauma-informed action plan is put into place.
RECOMMENDATION 11: The State Government to work with Derbarl to truly co-design “A Centre of Excellence for Aboriginal Children and Families”. The service model will be embedded within a culturally appropriate primary health care model, providing trauma-informed holistic care for children and their families. The strengths of Aboriginal culture will form the centre of this model and to focus on the first 2000 days of a child’s life.
The rights of Aboriginal children and their families to access high quality, holistic and culturally sensitive health care are inviolable. The benefits of changing how we manage children with neurodevelopmental disability through early intervention, wrap-around support and care for them and their families will be felt across the State and will result in profound benefits to the wellbeing of young children and their families in perpetuity.
Derbarl welcomes collaboration from the Western Australian State Government to realise our shared commitment to improve the health outcomes for our children.
Yours Sincerely
TRACEY BRAND
Chief Executive Officer