Media Conference

Terri, Young consumer of health services

PHELPS: Thank you for joining us here today. We have a very important youth health summit occurring today in Canberra, and I'm pleased to say that we have representatives here from over 30 key groups who are passionately interested in the issues facing young people today and impacting on their health. I am joined today by Joanne Murray, Commonwealth Bank and AMA Youth Health Advocate; Associate Professor Susan Sawyer, who's the Deputy Director of the Centre for Adolescent Health in Victoria; and Terri, who has a personal story that she's going to share with us today.

The AMA and the Youth Health Summit are working on a comprehensive youth health strategy. Youth health is a complex area, as with many areas of public health it crosses many portfolios, many areas of interest, and many areas of government. And what we would like to see is a better coordination of the efforts of all of the groups interested and involved in youth health so that we can have a better coordination of efforts. And I think with that coordination of efforts will come greater health benefits for young people. We also want to see greater representation for young people.

At the moment there's very little direct interface between young people and government, and particularly since the now defunct Australian Youth Policy and Action Coalition. And we want to see a clear national youth health policy developed, but with consultation with young people who these policies clearly most affect. With better coordination of youth health policy, we also want to see improved access to mainstream and specialist health services. And we particularly want to see some efforts put into place to enable access to health care services for people who are at the margins or who are at particular risk. And by that I mean people who are Aboriginal and Torres Strait Islanders, rural people, homeless young people, refugees, and culturally and linguistic diverse young people, so that our health services are able to cater not just for one main cultural group, but for people who are at particular risk. We're also looking at increased recognition of the needs of young people and greater understanding of youth issues and specific health concerns. So, once again, greater consultation with young people.

In order to improve access for young people to the health system, we are also renewing our call for Medicare cards to be issued to all Australians as soon as they turn 15, without them having to specially apply for that. We feel that that will help greater access. These are the brochures that we are releasing today. They have been designed with young people in mind, and they deal with very important health issues like smoking, gambling, depression, how to find a doctor, food, alcohol, fitness, stress and sexuality. And we feel that these are some of the main issues that are affecting young people's health, today. I'd like to now hand over to Associate Professor Susan Sawyer, who's sitting to my left. Susan.

SAWYER: I'd just really like to reinforce many of the comments that Kerryn Phelps has been making. I think that most of us in our community are aware that we really do have a crisis in youth health, whatever area we're in, whether it's drug and alcohol, whether it's sexual health, whether it's mental health, we must be very concerned about what we see. But I think that we also need to recognise that within our services, within our health services for young people, I really think it's equally a crisis. And I think we really need to look at better service coordination and in order to achieve that, we really need a whole government cross-portfolio approach. Because the organisation of services within the health portfolios need to improve. But equally, in terms of improving the health and well being of young people, this is far broader than health. We need to be much more concerned about the health and welfare of young Australians. They are clearly our future.

PHELPS: Thank you. I'd also like to introduce you to Terri.

TERRI: Hi, I've had - this is all incredibly intimidating. Sorry. Cameras and all sorts of things. Basically, the problem that I've had with youth services is that, yeah, they're targeted at youth, but they're inaccessible. And I don't mean 'can't get there', 'don't know how to get there'. I mean, you walk in there and you're faced with these professionals who basically just sit there and tell you what you want, what's best for you and what they're going to do to help you. And I've actually very infrequently been asked what my problem is and what I think I should do.

I think that what's needed in youth health services is actually support of the youth, by the youth. And I've just gone blank now. Sorry.

PHELPS: Terri will be able to answer questions from any of you as we go along too. I'd like to ask Joanne Murray to say a few words. Joanne is our Commonwealth Bank and AMA Youth Health Advocate.

MURRAY: Thank you. Basically the Commonwealth Bank AMA Youth Health Program is organised to generate awareness of important youth health issues, which we have done today, I think, very very well by holding this Youth Health Summit. We are looking to increase public awareness of the health needs of young people in Australia, and to develop and disseminate resources which we are launching today. We are looking to address the health and well being status of young people in Australia who face disadvantage, including Aboriginal and Torres Strait Islanders, homeless, rural, migrant refugee and young people from culturally and linguistic diverse backgrounds. We're also looking to improve the relationship between young people and the medical profession. To improve the quality of mainstream service delivery to young people, and to improve access to mainstream health services for young people. But, more importantly, we are also looking at specialised services for young people.

PHELPS: Any question to any of the panel members?

QUESTION: Dr Phelps, could I just ask how have we got to this situation and the crisis?

PHELPS: Susan, do you want to answer that one?

SAWYER: I think all over the developing world it's clear that participation in a whole range of health risk behaviours is increasing. Whether we're talking about drug and alcohol, whether we're talking about unsafe participation in sexual activity, whether we're talking about mental health. There are no simple explanations, but clearly there is something to do with young people feeling disempowered, young people not feeling a sense of encouragement of participation, not feeling that they have an obvious exciting future ahead of them. This has not come about because of any one single reason, but I think that in terms of what our response to it equally we need to be equally complex. There aren't any easy answers to the problem. But what this Youth Health Summit is about is trying to look at some of the ways that we might respond to that. And certainly we need to be increasing, I believe, the investment in provision of youth health services. Both those for specialty concerns, but equally across the board in terms of GP training.

QUESTION: Would you elaborate on why you think there is a crisis?

SAWYER: If we look at the rates of substance abuse within our community, if we look at the rates of mental health within our community, clearly there is a major concern. So any of the indicators of health risk would indicate - would suggest that they are going up. That if we look more broadly at our older population, the measures of health outcome are clearly improving. Young people are the only population group within our society whose health indices are not simply improving, but actually in many areas are getting worse. Given that we know that many of the health risk behaviours that young people participate in and start in adolescence actually have very major consequences beyond adolescence to adult and older life. Investment in youth health is clearly going to have substantial benefits, not just for young people at the time of adolescence, but equally in terms of throughout their life trajectory.

PHELPS: If you're asking yourself is there a crisis, you really need to look at one statistic to convince yourself. And that is that every day in Australia one young person takes their life with suicide. And we have 10,000 hospitalisations every year because of self-inflicted harm. Now, these are people crying out for help. And I think as a community and certainly as a medical profession, we have a responsibility to respond to that cry for help in the best way we can. And I think if the medical profession and government and all of the people who are interested in the welfare of young people in this country can work together, then we will find the solutions.

QUESTION: What do you see as the solution?

PHELPS: There's not just one solution. I think what we need to do is to take a very broad look at what is the problem, and as Terri mentioned, we need to ask young people what they want. What they see as the problems and what they see as the solutions. Terri, did you want to make any comments about what sorts of solutions you see? Pretend they're not there.

TERRI: Good luck. Well, the sorts of solutions that I'd be looking for basically do centre on support for youth, because you don't get support from when things like this happen. When you end up, as I am, in a situation where you have a severe mental illness that no one seems to understand or particularly be able to help with, sitting there and telling me, 'Well, haven't you tried this? Why don't you do that?' is not going to help. What I need is support. I need someone to sit there and say, "Well, yeah, you're having these problems, like what do you think?'

I know that one of my best experiences was with my case worker who would sit there and say, 'Yeah, that's all well and good, but you know what you need better than anyone else does. And then I'd move on to my psychiatrist, who'd say, 'I know what you need. You need drugs.' It doesn't work.

SAWYER: I think one of the problems that many high risk young people face is that part of the reason that they have ended up in the situation they are is that they're highly disconnected from a range of the supports within their environment. Whether that's their family. Whether that's peers, whether that's school, or even elements within a community. And I think one of the problems with our current response to youth health issues is that our own system of response, whether that's the mental health system, whether that's the health system in general, tends to be equally as fragmented and disconnected. So it's the lack of continuity within any single service provision, and Terri's example is of multiple difference workers involved all, if you like, cutting her up into individual bits and dealing one bit with another, rather than trying to understand that young people have a range of problems and that rather than having a mental health worker and a housing worker and a drug and alcohol worker and a case coordinator and a psychiatrist all within the one person, maybe we need as a service system to get our act together in a way that provides greater coordination of care to individual young people at risk. But also a better quality of care. And, so in that sense it's also training that we are needing.

TERRI: I think that the idea is to treat the person and not the problems, because in my experience you have the doctor who doles out the medication to keep you under control, and then you've got the social worker who deals with your family, a case manager who's supposed to be coordinating everything and really just sort of sits there and says, 'Well, I don't know what to do.' You have all these little bits and pieces and you're dealing with individual problems. You're not actually talking to the person at all. You're taking your little chunk and going, 'Right, I have this problem here.' It's not, 'I have this person who has a problem'. It's, 'I have this problem.' It's my job to deal with this problem, not to help this person.

PHELPS: So if we look at a summary of how we can deal with the problems facing young people who are having problems, then we need to look at a broad range of solutions. One of the solutions is to ensure greater coordination of all of the efforts dealing with youth health problems. The other is to listen to what young people have to say. And, of course, clearly there's a need for adequate funding to make sure that youth appropriate services are provided to the people who need them.

QUESTION: Who are young people most likely to talk to? Have there been any studies on that? Whether it's their - it's to do with counselling problems, is it going to be the doctor or the social worker?

SAWYER: There's been a recent study that came out at the start of this year looking at the mental health and well being of young Australians that suggested that in terms of those who get to see a health professional, that in terms of young people an equally high proportion of them are actually talking to GPs and paediatricians as they are specified mental health workers. And it's for that reason, I think, that we need to be very clear about improving the capacity of those within primary care, not simply within the mental health system, to improve the capacity to work with young people. So many young people are talking to GPs, but equally many young people are talking to school nurses, to welfare workers within schools. Are talking to their teachers. They're not talking to any health professionals.

QUESTION: Dr Phelps, given a couple of the issues that Terri's brought up with us here, with different people all getting involved in the issue. I guess things like coordination between governments and organisations who set like a very long term confused answer to get to the problems to help young people. In the short term, what can be done? This seems like to be a very long term plan? What can happen in the short term for those people who need help?

PHELPS: In the short term we can look at awareness and self-empowerment for young people. And one of the ways we can do that is to make sure that young people have access to Medicare on a confidential basis, which is the whole idea behind the call for Medicare cards for people at the age of 15. So that they can access confidential health services without having to worry about whether their efforts to receive help are going to be found out by people they don't necessarily want to find out that they're seeking that help. And quite often an effective intervention at an early stage of the problem will stop the problem becoming greater later on. So those are the short-term issues. Unfortunately the solution, if you like, to this bigger problem is a long-term solution. We're having a one-day summit here. We're not going to solve those problems here today. But what we can do is get all of these people together and begin the process of solving the problems that are facing the system as a whole. I mean clearly we have problems facing individual young people. We're going to try and address those, and I think some of those can be addressed in the short-term.

I think we need to look at new education programs for people who are health professionals working in this field, and GPs who may not see adolescent patients terribly often, but need to be well prepared when they do. And we need for young people to also know that they can go to their GP or to a youth health service and where to go. One of the reasons that we've come up with these brochures, and particularly the one about finding a doctor, is to empower young people that there are places that they can go for help. Those are the short-term solutions. Longer term we need to look at the system as a whole. For young people to be able to interface with government. There isn't that interface there at the moment. And that needs to be developed, and I would like to see that become government policy for whichever government is in power after the next election. I would like to see policies on the table before the election. And if we can get that interface then there will be a reality check for government policy. But similarly I think all government departments need to be able to work together and communicate well and coordinate efforts towards improving youth health.

SAWYER: I'd like also to add that young people do actually on average see their doctor at least once a year. Their GP. However, they're generally rocking up to see their GP with common garden variety health problems, rather than the range of broader issues such as the drug and alcohol, mental health, sexual health issues that we've been talking about this morning. In that sense we need to be able to improve the capacity within primary care to address some of the broader health issues that young people are not presenting with. If you like, the invisible health issues. And increase GPs capacity to deal with the breadth of problems, and that's going to require training.

TERRI: I would definitely agree with that. I know that in my experience adequate care, especially in the terms of mental health, is very difficult to get. The association known as Intake. Just how you get into the ACT mental health system is very very difficult to negotiate. I managed to bypass it by ending up in hospital after a severe overdose. That's the only reason I actually got any adequate care was it came to a crisis point and it shouldn't have to come to that. I shouldn't be lying in a hospital bed with a drip and, you know, still suffering the effects of activated charcoal before someone comes in and says, 'Okay, I think there's something wrong with this chick.'

SAWYER: And this is the problem in terms of much of the organisation and our health services currently, that we are very aware of the crisis, if you like, within the emergency department and the waiting lists for surgery. The number of patients and the number of hours that are needing to be spent on emergency department trolleys. That makes news for government. What isn't news is the requirement for early intervention, early recognition of problems such that Terri's faced, in order for us to address them prior to people rocking up in hospital because of a suicide attempt. Because of an overdose. Now, that's not sexy in terms of news. It's not sexy in terms of government. There aren't any easy solutions - if only there were.

What is needed is for us to step back and look at the broader organisation of health systems and services for young people. Look at the training that our health professionals are getting who are staffing those systems, trying to increase the voice of young people within those systems to ensure that they are more accessible for young people in order to prevent the sorts of problems that are all too commonly reaching the front news of our newspapers today.

QUESTION: Given that a lot of young people are probably like the rest of society, don't want to talk about their problems half the time, is it possible that doctors be given an incentive to inquiry of their patients? Like if they come in for a flu shot and they say, 'Let's talk about other things.'?

SAWYER: Firstly, many young people are very very comfortable talking about the major health issues and life issues that are affecting them if they know that that is going to be confidentially discussed. And in that sense the importance of automatic Medicare cards for young people when they are 15 is a very important element of increasing the likelihood that they will firstly be going to GPs and having an opportunity to discuss the important life issues they face. Young people are very comfortable talking about these sorts of issues.

QUESTION: What about the incentives, though, for the doctor to inquire? Then if he or she...

SAWYER: Okay. One of the major barriers that GPs describe in terms of spending the length of time that is required communicating with young people around the breadth of their problem is the current Medicare funding basis that relatively values short consultations over long consultations. There's been much work done over the past few years with the medical values study, to try to increase, if you like, the relative reimbursement for GPs that allow them to spend a longer time with that group of population that need it, such as young people.

QUESTION: Kerryn is this a possible trade off for the RVS?

PHELPS: This is the RVS.

QUESTION: Is this one crucial point of it?

PHELPS: I think one of the crucial points about - one of the crucial difficulties for general practitioners, as Professor Sawyer's mentioned, is that it is very difficult for GPs to be able to spend the amount of time that they need to spend with young people to draw from them the information that is required for the GP to understand a young person's life and their problems in the context. And, you know, while the young person might come along with a case of bronchitis or, you know, a cold and what they might really be wanting to come and talk about is some other much more deep seated fundamental problem that they're having with their family, or with their life, their problems at school, or you know personal self-esteem issues, and you know there are a whole range of things that that person might want to be able to talk about, but if it's a very rushed consultation you're not going to be able to spend that time. Now, if there was the implementation of the relative value study for general practitioners which enabled appropriate remuneration for longer consultations I think that would be a greater incentive to be able to spend more time with young people to talk about their problems.

QUESTION: Could you introduce a youth assessment in the way we have, you know, a sort of special item for the elderly, for example?

PHELPS: Yeah, the problem is that, number one, the assessments for over 75s in evidence-based studies have not been shown to have any particularly positive health outcome. So we would need some evidence that that would be useful. The second thing is we don't necessarily want to see more of these sort of tightly restricted item numbers. I think if we can simply spend more time with young people who have presented with a problem, just to find out more about their lives, about them as people, about what they're going through, how things are going at school, how are things with exams, how are they getting on with their parents and their siblings and their friends? Are they using drugs recreationally? Are they using alcohol and cigarettes? If so, why? Get in to these issues, which take time. And I mean part of that time is confidence building. Trust building. Because you can't just hit somebody with a range of intensely personal questions and expect them to spill their guts just because, you know, it's probably a good time and place. I think you have to be able to build confidence and trust with someone. Part of that is their knowing that they have confidentiality of that discussion.

QUESTION: On that issue, how often is it that people do go back to exactly the same doctor? I mean rather than simply going to a doctor within a practice, which normally happens?

SAWYER: We don't have that data available in Australia. But what's very clear is that young people who have a relationship with a GP, who feel that they can trust that GP, who feel respected and empowered by that GP, we know are far more likely are to go back to them and be able to actually start to address some of these root cause issues.

QUESTION: But if someone's visiting their doctor once a year, say, and their practice is full of people, then it's likely that this person they're seeing is a complete stranger?

SAWYER: No, if someone is visiting a doctor for a cold and so is a one-off problem and they wouldn't generally be choosing to go back to them again, however in terms of that consultation they recognise that this person seems to be caring, compassionate, is concerned about the broader issues that they face, that doctor, if they are doing their job, will hopefully then arrange another appointment for that young person to start to address some of these broader issues so that it will then be an opportunity to start to look at some of the deeper concerns. This can very clearly happen within general practice, however it's not simply a matter of time and reimbursement. It's also the quality of that relationship, and we know that GPs can do very well to improve the quality that they can provide within that doctor/patient relationship with young people by specific training.

Work that we've done at the Centre for Adolescent Health looking at a randomised control trial of training a group of GPs in the principles of working better with young people, has very clearly demonstrated that brief training interventions can improve GPs confidence about working with young people. It can improve their attitudes towards the likely opportunities to work positively with young people. And, indeed, in terms of formal evaluations, really does improve the skills and competence with which they are starting to be able to address these issues. So we need money, in terms of reimbursement of GPs time, which if you like is the incentive, but we equally need to ensure that that time with young people is well spent. So we need greater opportunities for training general practitioners.

TERRI: However, things like incentives and training and what have you, anything that you can implement is useless if the young person doesn't want to talk to you. And that can happen for any number of reasons. It could be they don't like you, they don't trust you, you're old. You look like my father. You'll tell my mother. Any of these things that may seem arbitrary and fairly petty, but these are big things. I know that confidentiality is, yes, a major issue. The fact that until you turn 18 they can tell your parents. That is a majorly…

SAWYER: No, no, they can't.

TERRI: At 16 they have to tell you…

SAWYER: No, no, they can't. Fourteen.

TERRI: Fourteen, they've changed it? Wow, well when I first came into the system it was until you turn 16 they could tell your parents if it endangered your life or someone else's. And that would - that could include things like smoking marijuana, just it's at the doctor's discretion. The thing is that your medical professional has a lot more power than the young person does, in that they can make that choice and they have to make that choice. And the young person doesn't really have a say in it. They can go, 'Hey, wait a second.' That's not fair, but…

SAWYER: We, as adults, expect confidentiality of our health care providers. Young people not having that same experience of the health care system, simply assume that whatever the age, under the age of 18, if you go and see a doctor of course if there are sensitive issues that are discussed you're going to go and tell mum and dad. You can imagine that for young people living in rural communities where maybe the GP is mum and dad's best mate or plays tennis with them or is on the school committee, that that genuine sense that their health issues will be dealt confidentially with is very very difficult to achieve.

It is the responsibility of us as health care providers to be really ensuring that young people truly understand that the health issues that they will be presenting with really will be dealt with confidentially. I think, as Terri has said, and certainly the research data very strongly supports that young people are far more likely to return to GPs, be honest with GPs about the behaviours they're participating in, and also to be able to feel comfortable working with that GP to start to address some of those issues that are affecting them. It's a very important part of access to health care.

QUESTION: Terri, when did your story start with your first contact with …

TERRI: Well, my first contact with the health system - with the - I know that I think things started going badly for me. I went crazy, I suppose is the best way to explain it. And I took a major overdose. Basically I think my parents had sent me to a private psychologist for a while, but I was told by my parents - and I'm going to get in trouble for this - that they couldn't really afford for me to keep up with this silliness. That now was the time to tell the truth so on and so forth. So there's, you know, the support from my parents has gone. I then - things got continually worse for me and I ended up actually in the adolescent ward at the Canberra Hospital. I was kept there for two weeks, and it just sort of went from there. I accumulated all of these case managers. It sort of happened without me doing anything, in which respect I was incredibly lucky. Well, not lucky that I ended up in hospital for a severe overdose and that's how it started. But I didn't have to go through intake. I didn't have to go through all the assessments. I didn't have to have them talk to my parents, talk to - find out a history, that sort of thing. It was just bang. Crisis.

QUESTION: You had a collision with the system?

TERRI: Yes.

QUESTION: Than actually being helped.

TERRI: But the fact that it had to come to a crisis point or I would have had to fight for help.

QUESTION: How old were you then?

TERRI: Fifteen.

QUESTION: And as your experience, do you talk to other people and…

TERRI: Yes, I have. And they all seem to have similar problems. I've also spoken to many youth workers, or social workers, people who work in things like CAMS, the Child and Adolescent Mental Health System, and also in the adult health system, who are all very dissatisfied with the way that it works and the lack of continuity and the - just the attitude towards young people especially when they're going through the transition from adolescent to adult mental health. It's a big jump, because there is this huge grey area between when you stop being a child and when you start being an adult. You sort of - no one knows how to deal with you. They don't know how to talk to you, and whether it's, you know, with the best of intentions or anything, you tend to be patronised. They tend to take control. Hide behind their degree or title, 'I'm the doctor, you're the patient', which also is a major barrier for young people because - well, you're brought up that this is your parent. You know, there are certain things that you don't say or do in front of your mother, your grandmother. And you've got this doctor, which is effectively the same thing. You then, yeah, they're a completely different person. They're not part of your family. But they have that division, that distinction. This is a doctor.

QUESTION: Feeling sorry you think he knows?

TERRI: Yeah.

PHELPS: I have to say this is a frustration for GPs as well, because if we are faced with a person that we know is heading for a collision, quite often we actually have to wait for them to have the collision before we can access the services on their behalf too. So much is - you know, that means that there is quite actually a degree of responsibility placed on the GPs shoulders because they don't have the community supports to be able to recruit to help the young person until they do actually hit a wall. So what we really need to see is an over-arching national youth health policy where we have better coordination and where young people are able to express their problems. And where the medical profession can also have input and both on a level of informing and of learning.

But we'll have to wrap it up there, because our summit has to proceed. But I'd like to thank you all very much for coming along. And some of the participants in the summit today will be available for further interviews outside, if you'd like. Thank you all very much.

Ends