Mental Health and Alcohol and Other Drugs Needs Assessment Gold Coast

Gold Coast Primary Health Network
Gold Coast Primary Health Network – Mental Health, Alcohol and Other Drugs Needs Assessment 1
Mental Health, Alcohol
and Other Drugs
Health Needs
Assessment

Acknowledgement of Country
We acknowledge the traditional custodians of the land on which this report was developed and produced, the Yugembeh, Yuggera and Bundjalung
peoples. We also would like to pay respects to Elders both past and present, and extend that respect to include all Aboriginal people of today.
Gold Coast Primary Health Network gratefully acknowledges the financial and other support from the Australian
Government Department of Health
While the Australian Government Department of Health has contributed to the funding of this material, the information contained in it does not
necessarily reflect the views of the Australian Government and is not advice that is provided, or information that is endorsed, by the Australian
Government. The Australian Government is not responsible in negligence or otherwise for any injury, loss or damage however arising from the use of or
reliance on the information provided herein.
Disclaimer
While every care has been taken in the preparation of this document Primary Care Gold Coast Trading as Gold Coast Primary Health Network (GCPHN)
accepts no responsibility for decisions or actions taken as a result of any data, information or statement expressed or implied within this document.
Although data has been derived from sources believed to be reliable, GCPHN does not guarantee or make any representations as to its accuracy or
completeness. Consultation statements have been derived from conversations and engagement processes with service providers, service users and
other concerned parties and express personal opinions and experiences and GCPHN does not necessarily endorse or confirm those expressed opinions.
GCPHN disclaims all responsibility and all liability for all expenses, losses, damages and costs that may be incurred as a result of information being
inaccurate or incomplete in any way and for any reason. This disclaimer applies to the maximum extent permitted by law and, without limitation, to
liability arising in negligence or under statute.
Copyright
© Primary Care Gold Coast Ltd Trading as Gold Coast Primary Health Network (GCPHN).
Published September 2016. GCPHN supports and encourages dissemination and exchange of information, however, copyright protects this publication.
GCPHN has no objection to this material being reproduced, made available online or electronically but only if it is acknowledged as the owner of the
copyright and this material remains unaltered including references to original data sources.

Table of Contents
Acknowledgement of Country 2
Disclaimer 2
Foreward from the CEO 4
Executive Summary 5
1. Why is GCPHN Region conducting a Health Needs Assessment? 11
1.1 Introduction to mental health reform 11
1.2 What is commissioning? 12
1.3 What is in scope of this Health Needs Assessment? 12
1.4 How was the Health Needs Assessment undertaken? 12
2. Overview of the Gold Coast Primary Network (GCPHN) region 17
2.1 Map of the GCPHN region 17
3. Mental Health 24
3.1 Youth (including children) 24
3.2 Indigenous (mental health and suicide) 30
3.3 Suicide prevention 34
3.4 Low intensity services 39
3.5 Hard to reach groups 43
3.6 Severe and Complex 52
3.7 Alcohol and other drugs (incl. Aboriginal and Torres Strait Islander people) 65
4. Conclusions 74
4.1 Youth (including children) 74
4.2 Indigenous (mental health and suicide) 74
4.3 Suicide prevention 74
4.4 Low intensity services 75
4.5 Hard to reach groups 75
4.6 Severe and Complex 75
4.7 Alcohol and other drugs (mainstream) 76
4.8 Alcohol and other drugs (Indigenous) 76
5. Linkages 77
6. Next steps 78
7. Appendices 79
7.1 Acknowledgements 79
7.2 Figures 80
8. Bibliography 82

Foreword from the CEO
In November 2015 the Commonwealth Government announced its response to a Review of Mental Health Programmes
and Services in Australia which set out a challenging and more comprehensive role for Primary Health Networks in
planning and commissioning primary healthcare services, particularly treatment services that address the nationally
prioritised health needs for people with mental health and alcohol and other drugs issues. A key area of the reform is
that Primary Health Networks progress the re-design and provision of services within a stepped care model that better
matches services to individual needs.
This document presents findings from the work that the Gold Coast Primary Health Network has commenced to improve
mental health and alcohol and other drugs services and health outcomes locally. A key platform of this work has been
undertaking an in-depth local needs analysis.
This thorough analysis involved consideration of a broader range of data, local service mapping and comprehensive
engagement with local service providers, key stakeholders and importantly service users themselves to verify the process
and key findings. The analysis focuses on the six nationally prioritised key mental health and two alcohol and other drugs
focus areas specified in the Commonwealth Government’s reform program.
The results of this process have been verified by both our internal governance processes, including our Clinical Council,
Community Advisory Council and Board, as well as by key external stakeholders such as local service delivery agencies
including the Gold Coast Hospital and Health Service. A supplementary online survey engaged a broader range of
stakeholders in this verification process.
The resulting identified health and service needs form a strong, shared basis for Gold Coast Primary Health Network to
work with our local sector to improve the coordination of services and increase the efficiency and effectiveness of health
services towards better addressing the health and wellbeing of residents in our region.
The Gold Coast Primary Health Network team would like to thank everyone involved in this extensive consultation
process and in the development of this document. In particular, the individual service users who so generously shared
their stories and experiences to help inform how we set about improving services to better meet identified needs.
This document presents information at this point in time. It is a product of an ongoing needs assessment and service
evaluation process, whereby we will continue to identify new, relevant information, engage with the sector and service
users, and build our knowledge about the contemporary and relevant needs of our local community as it continues to
evolve.
Matthew Carrodus

Executive Summary
This document provides an introduction to mental health and alcohol and other drugs issues as they present in the Gold
Coast Primary Health Network region. The document is structured to provide a snapshot profile of the Gold Coast
community and the prevalence and incidence of mental health and alcohol and other drugs in the region. In addition to
this overview, information is presented in sections covering the nationally prioritised six key mental health and two
alcohol and other drug focus areas for reform. These sections outline the prevalence, incidence, service usage, service
mapping, feedback from service providers and service users followed by a summary of the needs identified and resultant
key findings.
Consideration of the data, the consultation and the service mapping has identified a number of common overarching
themes. These include:
Mental health and alcohol and other drug issues rarely exist in isolation, dual diagnosis and co-morbidity are
very common and require coordination across service providers and clear pathways to support clients.
Building knowledge and understanding among service providers in relation to vulnerable groups is required to
ensure accessibility and effectiveness of services.
The important role of general practice as a first point of contact and a coordinator of care.
The northern growth corridor (centred around Oxenford-Ormeau) has been identified as having less services
accessibility than other regions within the Gold Coast.
Care coordination and/or support is needed for people with alcohol and/or other drug issues as they wait for
more intensive treatment options.
Early identification at school is important to provide children with the most optimum mental health
intervention.
Access to psychological services for people from culturally and linguistically diverse backgrounds, LGBTIQAP+,
homeless people, children and Aboriginal and Torres Strait Islanders.
Information and training for General Practitioners is needed, especially in relation to severe and complex mental
illness and drug dependence such as ICE.
Development of clear referral pathways to increase opportunities to ensure appropriate care planning and
discharge processes are necessary for people who have attempted, or are at risk, of suicide.
At a focus area level, key findings and needs by topic are detailed in the following points:
Youth (including children)
Key findings
Data indicates potential geographic areas with higher numbers of vulnerable young children (prep year) are in
the northern growth corridor areas of Upper Coomera and Pacific Pines as well as the central Southport areas
and consultation indicates service gaps in the northern growth corridor.
Broadbeach-Burleigh, Southport and Ormeau-Oxenford are highlighted areas with significantly higher than
national rates for prescribing mental health medication for those under 18.
There is a concentration of services in the Southport area including the large youth health service, Headspace.
Age and other access criteria varies across the sector and consultation and service mapping indicates that access
to services for younger children (aged zero to 14) is more difficult. This is also supported by data from the
GCPHN’s ATAPS program which saw significant increase in referrals following marketing to potential referrers.

Consultation highlighted the importance of schools as an early intervention opportunity for young people.
Services report an increase in high complexity for young service users requiring coordinated, family based and
multiple agency response.
On some indicators, the GCPHN region fairs slightly better than state and national comparators such as: lower
rates of prescriptions for antidepressant and anti-psychotic medication for under 18’s and a lower proportion of
youth suicide (refer to Mental Health, Youth (including children) page 24).
GCPHN needs to work with stakeholders to improve regional specific data on prevalence and service usage by
children and young people for future analysis.
Needs
Improve access to services that provide wrap around support for youth through outreach opportunities and
service entry points that are flexible and youth focused.
Increase early intervention and therapeutic services for children aged zero to 14 across the region with a focus
on the northern growth corridor.
Increase school education workforce capacity for early identification and intervention.
Indigenous (mental health and suicide)
Key findings
Gold Coast has a relatively small Indigenous population with higher density in Coolangatta, Nerang, Ormeau-
Oxenford and Southport.
There are limited Aboriginal and Torres Strait Islander specific mental health services and workers; cultural
needs are not well met by mainstream service providers.
Uptake of the dedicated ATAPS Aboriginal and Torres Strait Islander service is quite low, varying between 1 – 9
referrals a month over the last two years.
There can be stigma associated with Aboriginal and Torres Strait Islander people seeking treatment, and for men
there can be “shame” associated with accessing services.
Mens’ groups in the north and south of the region are engaging Aboriginal and Torres Strait Islander men well
and could be expanded on.
Needs
Enhance the Indigenous workforce to enable workers to provide care coordination and specialist mental health
services, including suicide support.
Increase coordination of services using well-developed trusted pathways to support client referrals to culturally
appropriate services.
Increase the cultural competency of mainstream services to safely and effectively work with Aboriginal and
Torres Strait Islander clients.
Suicide prevention
Key findings
While the Gold Coast suicide rate is lower than state and national rates, the rate of episodes of care for suicide
and self-inflicted injury is increasing over recent years.

Gold Coast data indicates that men account for around 70% of suicides, and 35-54 year age groups experience
the highest number of suicides; hanging is the most common method.
National data clearly indicates the LGBTIQAP+ community is particularly vulnerable.
There is value in ensuring an understanding of the warning signs of suicide in General Practice and community
services.
The interface with acute services remains problematic, including: a lack of appropriate referrals when patients
seek help who are not severe enough to meet admission eligibility; limited collaborative discharge planning and
discharge information; discharge information may not always be received in a timely way by the usual GP.
While consultation indicates that there is limited availability of dedicated community support, the ATAPS suicide
referral numbers remain quite small.
Needs
Increase knowledge and skills of General Practice and mental health services workforce particularly in relation
to specific groups including men and the LGBTIQAP+ community.
Increase opportunities to ensure care planning and discharge processes are inclusive for all participants.
Develop clear referral pathways and supported connections to appropriate community supports.
Low intensity services
Key findings
While there are a broad range of quality online and telephone services (eMH services) available for people with
low acuity mental health issues, there is very limited local data on the number and coverage of “counsellors”
and evidence based support groups and group sessions of psychological support.
There are limited integration of eMH services as complementary service options into primary health care service
delivery.
Consultation indicates effective early intervention can prevent deterioration but there are limited soft entry
point models (coaching, peer-support, wellness focussed that focus on social and community connectedness).
From a client perspective, a significant positive impact on recovery can be gained by General Practitioners
referring services that fit the needs of the client. For example, treatment options can be augmented through the
use of community based self-help groups and soft entry services that use activities to engage clients and build
their skills and confidence.
Needs
Identify and develop flexible evidence based services, including group sessions.
Undertake information campaign to General Practice to ensure services developed are communicated
appropriately and made accessible.
Develop effective pathways to increase accessibility to evidence based electronic (digital) mental health
services.
Hard to reach groups
Key findings
A broad range of languages are spoken in the region, including growing numbers from countries where trauma
and torture issues impact on individual’s ability to access appropriate services.

Use of interpreter services can be difficult, particularly telephone based services, as interpreters may have
limited understanding of mental health issues and cultural sensitivity as well as limited capacity of CALD services
to support mental health clients.
Stigma, privacy concerns and cultural issues can act as barriers to people accessing services.
Flexibility of service provision, such as outreach, is necessary to engage the homeless population.
Training and education is required for services to ensure safe and appropriate service provision for the
LGBTIQAP+ population.
Providing psychological services to these hard to reach populations was identified as an important need.
Needs
Housing options are needed to stabilise and support effective engagement with primary care mental health
supports for the homeless population (out of scope but will be progressed by PHN).
Effective engagement between community and primary health services would better support the homeless
population.
Increase access for the CALD population to psychological services and/or clinicians, including appropriately
mental health trained interpreters.
Increase accessibility and referral pathways for LGBTIQAP+ people to appropriately skilled clinicians and services
to support the needs of this group.
Severe and complex
Key findings
Increased support and upskilling opportunities for GPs to better meet the needs of severe and complex patients
within the bounds of time limited consultations, and using appropriate referral pathways.
Increased service capacity for outreach services to areas such as the northern growth corridor with a particular
focus on flexible and multi-needs models of care.
Improved pathways to support patient centred and effective transfer of care between acute, specialist and
primary care services (i.e. general practice, allied health and community services).
Most recent estimates of population with mental and behavioural problems indicate the Gold Coast region has
comparable rates to the Queensland figures, with higher rates for females compared to males.
Many data sets indicate growing use of mental health services through MBS and the public health system. In
terms of MBS while the number of patients receiving services has significantly increased the number of services
per patient has been reducing (except for psychiatry), with Ormeau-Oxenford in northern growth corridor
emerging as an area of potential reduced service coverage.
Consultation with community service sector indicates mental health services are at capacity and there are wait
lists up to three months for many programs.
PBS data indicates rates of prescriptions for medication for adults are higher than national average for
anxiolytics but lower for anti-depressants and anti-psychotics. This could indicate difference either in
prevenance or prescription patterns. Southport SA3 was the area of highest prescriptions across all three
medications. Southport was also the areas with the highest number of contacts with public mental health
services. Most services are also located in Southport area.

General Practice is seen as a key point of contact for people with mental health issues (the main coordinator of
care for 14% of people with severe and complex needs in the PIR program) and this is supported by practice
data and the very high rate of mental health treatment plans locally compared to national rates. However many
GPs feel they do not have information and resources required to assist patients with severe and persistent
mental illness. While patient feedback regarding mental health nurses in general practice is very positive, this
service appears to be underutilised in our region and not necessarily aligned to greatest areas of need.
Consultation indicates barriers to access include stigma, transport, cost of housing and a lack of trust in service
providers by service users.
Service users indicate a more flexible, holistic approach to support the whole person rather than just treating a
diagnosis is preferred and more effective; connection to community was an important element.
There is limited peer support available for people with severe and complex mental health needs.
There are issues with the acute services interface, which include high acuity access criteria, limited collaborative
discharge planning and discharge information not always being received by usual GP in timely way.
Concern regarding impact of NDIS commencement of services for people with severe and complex mental
health needs.
Needs
Increase support and upskilling opportunities for General Practice to better meet the needs of severe and
complex patients in time limited consultations and to develop appropriate referral pathways.
Better utilisation of Mental Health Nurses in the region to work with individuals with severe and complex
mental health issues.
Increase service capacity for outreach services to areas such as the northern growth corridor with particular
focus on flexible and multi-needs models of care.
Develop effective pathways to support patient centred transfer of care between acute care services and primary
care services (general practice, allied health and community services).
Alcohol and other drugs (including consideration of Aboriginal and Torres Strait Islander)
Key findings
Alcohol, followed by cannabis, remain the most common drugs of concern in the GCPHN region although ICE is
reported by service providers to be fast emerging as a significant concern across the sector and community.
There is a strong correlation between mental health problems and alcohol and other drug use.
Men are more likely to seek treatment for alcohol and other drug use and the Gold Coast has a particularly high
rate of younger people (under 20) seeking treatment. However, treatment options for under 18 are very limited.
There are very limited options available for people with families to access alcohol and other drugs treatment
services.
Limited detoxification services are available and report that they often have no capacity to immediately accept
clients without delays or accept people who are still using or have other health problems.
Most treatment services on the Gold Coast are outreach rather than residential and there is a preference for
this more flexible style of service from consumers. High rates of treatment completion in the region may also
support this service model.

Service gaps exist in the northern growth corridor with the majority of treatment services located from
Southport to Burleigh.
There is limited information, resources and support available for General Practice in alcohol and other drugs
use, particularly for methamphetamine use.
Needs (mainstream)
Increase capacity of detoxification, residential rehabilitation and aftercare services to provide flexible support
and follow up for clients as well as enabling people still using substances to access services.
Flexible outreach treatment services with a focus on vulnerable target groups including young people and
people with families.
Provision of training, referral pathway education and resources with managing General Practice to support
patients with substance use issues including ICE.
Needs (Indigenous)
Increase capacity through existing Aboriginal and Torres Strait Islander service providers in relation to early
intervention and care coordination for clients.
Increase workforce capacity to assist client access to culturally appropriate services for substance use
treatment.
Increase the cultural competency of mainstream alcohol and other drugs treatment services to safely and
effectively work with Aboriginal and Torres Strait Islander clients.

Gold Coast Primary Health Network – Mental Health, Alcohol and Other Drugs Health Needs Assessment 11
1.Why is GCPHN region conducting a Health Needs
Assessment?
1.1 Introduction to mental health reform
Conducting the Health Needs Assessment is an essential step in developing a region-wide service plan for mental health,
alcohol and other drugs health needs in the GCPHN region. It will allow GCPHN to identify, crystallise and prioritise the
health needs in the Gold Coast area, and will form the genesis for investment in key areas. A Health Needs Assessment is
a systematic method of identifying unmet health and healthcare needs of a population and making changes to meet
these needs.
In the Australian Government Response to Contributing Lives, Thriving Communities – Review of Mental Health
Programmes and Services, the Australian Government sets out a new approach to mental health funding and reform
with the following key elements:
Person centred care funded on the basis of need
Thinking nationally, acting locally – a regional approach to service planning and integration
Delivering services within a stepped care approach - better targeting services to meet needs
Effective early intervention across the lifespan – shifting the balance
Digital mental health services – making optimal use of Australia’s world leading technology
Strengthened national leadership – facilitating systemic change
The Stepped care approach is a fundamental aspect of the reform and figure 1 below sets out the system changes to
strengthen the stepped care model in primary mental health care clinical service delivery.
Figure 1 Stepped Care Approach

1.2 What is commissioning?
Commissioning is the process of assessing the needs of the community, designing services to meet those needs, selecting
the best and most appropriate service providers, purchasing those services on behalf of the community and monitoring
delivery to ensure the needs are addressed and outcomes produced.
GCPHN will be commissioning healthcare services in relation to mental health reforms across the Gold Coast region. To
achieve its objectives and to ensure that patients and consumers have timely access to well-coordinated preventative
and primary healthcare the PHN receives funding, primarily from the Commonwealth Department of Health and
determines how to direct these funds based on local needs.
1.3 What is in scope of this Health Needs Assessment?
The key objectives of a Health Needs Assessment are to inform the commissioning processes for GCPHN including:
Determine the broad health themes in the GCPHN region for effective health planning and intervention;
Inform the annual planning and evaluation processes of GCPHN; and
Provide a sound evidence base to enable effective health program co-design and delivery.
This Health Needs Assessment provides a deep dive into the areas of mental health and alcohol and other drugs.
Focus areas were determined to align with the key Commonwealth priority areas in the mental health and alcohol and
other drug reforms as listed below:
Mental health:
Youth (including children)
Indigenous
Suicide prevention
Low intensity services
Hard to reach groups
Severe and complex
Alcohol and other drugs:
Mainstream
Indigenous
The definitions for each of these focus areas are included in the relevant sections to follow.
1.4 How was the Health Needs Assessment undertaken?
Conducting a Health Needs Assessment is not an isolated project or report. It requires extensive co-ordination and
collaboration across service lines and is a constant work in progress throughout the year.
There are three key elements that come together to build a Health Needs Assessment. They are:
Quantitative data on key health and population statistics

Consultations with stakeholders and service users
Service mapping
These three elements, applied together and complimented by localised health expertise, form the Health Needs
Assessment. Figure 2 graphically shows how the three elements come together to form the Health Needs Assessment.
Quantitative data on key health and population statistics
Throughout the year, GCPHN has been constantly gathering and requesting key data sets to inform the Health Needs
Assessment. There were three levels of data that were collected throughout the year including:
National and state level data, such as prevalence estimates for particular groups
GCPHN region level data, such as episodes of care in hospitals from Queensland Health
Statistical Area 3 (SA3) level data, population demographics and socio-economic conditions that describe the
nation as a whole sourced from the Australian Bureau of Statistics, health professional services, prescription
information data and Medical Benefits Schedule data, Pharmaceutical Benefit Schedule and National Health
Performance Authority data.
Having access to these three levels of data allows for simple and powerful comparisons on key statistics affecting the
population of the GCPHN region. This level of analysis allows GCPHN region to identify not only national and state health
trends, but also to view the different SA3s in the area as distinct regions, each with their own unique issues and
challenges.
Consultations with service providers and service users
As with quantitative data, GCPHN has been regularly conducting stakeholder and service user interviews and feedback
sessions throughout the year. Consultations took many different forms, such as:
Figure 2 The process of conducting a Health Needs Assessment using the three elements

Public workshops
PHN advisory councils and other committees
Detailed service provider interviews
An initial GCPHN service mapping exercise was conducted in January 2016, focussing on Mental Health and AOD services.
This sought to identify location, service footprint, operating hours, services/programs provided and funding source. The
intention of the exercise was to identify program capability, capacity, accessibility and eligibility criteria with a focus on
NGO/community service providers. The data collection was limited to existing publically available data on web sites and
on line information in the first instance, with telephone follow-up supplementing information. While every endeavour
was made to collect comprehensive information on all services, gaps do persist.
GCPHN identified and used the Harvard Business School, Deep Dive methodology to inform the more detailed qualitative
data gathering from 19 key mental health and alcohol and other drug service providers. This methodology was chosen
as: “…the concept of a deep dive, is an intervention when top management seizes hold of the substantive content of a
strategic initiative and its operational implementation at the project level, as a way to drive new behaviours that enable
an organization to shift its performance trajectory into new dimensions unreachable with any of the previously described
forms of intervention…”.
Data from the initial service mapping exercise was the source document, point of comparison and a good starting point
for the Deep Dive. Collaborative decision making was used to identify which services should be included in the GCPHN
Deep Dive activity. Inclusion criteria related to service profile and service provision. The services included were subject to
some change as the deep dive process exposed important linkages to services that were not originally included.
Prior to the face to face interviews, multiple contacts were made with participants to support rapport building. An
introduction was sent electronically, outlined key GCPHN objectives, the National Mental Health and Alcohol and Other
Drugs Reforms, local stages of the reform and also introduced the GCPHN Mental Health AOD team. An online
questionnaire was designed comprising of 58 questions, this was also sent to participants electronically for completion
prior to the visit. This expedited the meeting and allowed for more focused discussions though having richer context on
particular issues/areas of service delivery.
The service visit interviews were conducted by 2 experienced Project Officers. Field notes were taken and captured
anecdotal impressions that were provided conversationally by participants and were not captured by the electronic
survey. The diversity of the data capture methods yielded previously undocumented impressions from service providers.
Following the interviews, a Service Snap Shot was created for each interviewed service detailing the key issues for the
service employees. A key feature of the Snap Shot was to profile positive, unique and different aspects of services
including stories of how staff went above and beyond expectations to meet the needs of their client group. These Snap
Shots were provided back to interviewed services, furthering rapport for future commissioning processes. Feedback
indicates services were receptive to having aspects of the work they do show cased.
A rigorous analysis of the extensive qualitative data collected through consultation was undertaken by an independent
academic from Griffith University to ensure:
Sufficient involvement from each representative interest group, consumers and service providers
Reasonable power balance in the collection of data (not marginalised voices)
Sufficiently similar focus on purpose for data collected and therefore similar content outcomes
Ethical processes used for data collection (assessed from discussions held with staff involved).
The themes that emerged validated the processes undertaken by GCPHN where priorities for the sector existed, and
provided focus to assist in the consolidation of further inputs.

Service user journey mapping
A journey map is a diagram summarising the service experiences a person has over time. It is used to help identify,
understand and visualise the different touch points in the consumer’s health journey. The process involves a facilitator
guiding discussion of a consumer’s personal journey (what services were accessed, how they were accessed and what
the consumer felt throughout this). A writer documents details of the conversation to illustrate connections between the
phases of experience. In the majority of sessions, a graphic recording of the journey was also produced (example below).
The voice of the consumer is critical to effective commissioning. Documenting the consumer journey was a vital
component of the GCPHN Mental Health and Alcohol and Other Drug Needs Assessment. Criteria for participation were:
Experienced an episode of treatment on the Gold Coast in the last five years
Available for a two-hour mapping session
Most importantly, the participant felt confident in their wellness to be able to tell their story
GCPHN conducted nine interviews in total. Participants unanimously agreed that involvement in the mapping assisted
their recovery journey and was a way of telling their story to an appreciative audience. In all mapping sessions mental
health and AOD professionals were present to provide support to participants should this be required. Data from the
interviews contributed to the needs assessment and became a validation mechanism for the Deep Dive interviews.
Figure 3 Example of a graphic recording produced in a journey mapping session

Service Mapping
Service mapping requires direct input from the providers of health services in the GCPHN region. Key data around what
services are being offered in the area was gathered from General Practices, allied health professionals, hospitals and
other health and community providers in order to discern the location and availability of health services on the Gold
Coast.
Triangulation
Through a process of extensive co-ordination, these three elements were bought together to build a cohesive message of
the health needs of the Gold Coast. Each of these three elements were first examined in isolation to discern whether the
elements alone were indicating a health need. Once this process was exhausted, the three elements came together, to
inform, challenge, reinforce and validate initial health need indications.
The result was that GCPHN was able to identify clear and coherent messages surrounding health needs in the Gold Coast
area, with an evidence base in all three elements. This powerful synthesis of data provides a solid foundation upon which
the GCPHN can confidently base prioritisation and investment decisions.

2. Overview of Gold Coast Primary Network (GCPHN)
Region
2.1 Map of the GCPHN region
Figure 4 Map of the GCPHN region

Figure 5 Gold Coast Population Key Statistics
Overview of mental health on the Gold Coast
The 2007 National Survey of adult Mental Health and Wellbeing (NSMHWB) provides information on the previous 12-
month and lifetime prevalence of mental disorders in the Australian population. It was estimated from the survey that
45% of Australian adults (7.3 million people) will experience a mental disorder at some time in their life. It was also
estimated that 20% of the population (3.2 million people) had experienced a common mental disorder in the previous 12
months. Applying the national ratio to the Gold Coast’s 2014 estimated residential population aged 16 years and over
suggests an estimated 91,600 people in the region experienced a common mental disorder in the last 12 months.
The National Mental Health Commission's National Review of Mental Health Programmes and Services – Contributing
Lives, Thriving Communities, 2015, notes that mental health spans a broad spectrum of conditions.

Figure 6 Estimated annual distribution of mental ill-health in Australia
Applying these figures to the Gold Coast’s 457,837 people aged 16 years and over leads to an estimate of:
Around 63,000 Gold Coast residents with mild to moderate mental illness
Around 14,000 people with severe mental illness (including severe episodic, severe and persistent, and severe
and persistent with complex multiagency needs)
Many people with experience of mental illness do not seek support for their condition, with statistics suggesting only
about 46 per cent of people with a mental ill-health problem seeking help each year.
Data indicates the rates of people with a mental health problem in the GCPHN region are similar to the Queensland rates
overall. In figure 7 below the graph highlights a significantly higher number of females (43,476) with mental
health/behavioural problems than males (34,437).
Figure 7 Number and age standardised rate per 100 by selected groups in the Gold Coast and Queensland areas, 2011-13
The vast majority of primary care services are funded through the Medicare Benefits Schedule (MBS). According to MBS
statistics in the 2014-2015 financial year over $110,978,894 of fees were charged for mental health related services
across the GCPHN region amounting to just over 1/5 of the total MBS expenditure.
10
11
12
13
14
15
16
17
Estimated male population with mental
and behavioural problems
Estimated female population with mental
and behavioural problems
Estimated population with mental and
behavioural problems
Ageadjustedrateper100
Gold Coast age adjusted rate per 100 Queensland age adjusted rate per 100

Figure 8 GCPHN region expenditure for all MBS services, FY15
GCPHN region expenditure MBS Data Fees Charged FY15
Psychiatrist $37,751,275
Psychologist $23,569,135
General Practitioner $21,634,864
Other Allied health Services $28,023,620
Mental Health MBS expenditure $110,978,894
TOTAL MBS expenditure $419,336,932
Figure 9 Total GCPHN region MBS expenditure, FY15
In 2015-2016 GCPHN has allocated $8,095,076 towards mental health services including the Access to Allied
Psychological Services (ATAPS), Mental Health Nurse Incentive Program, Headspace and Partners In Recovery (PIR).
Figure 10 shows the proportion of GCPHN mental health expenditure compared to the MBS mental health expenditure in
the GCPHN region.
Figure 10 GCPHN mental health expenditure compared to mental health MBS expenditure
This does not include services delivered through Gold Coast Hospital and Health Service, private health insurance
providers and the many non-government/community organisations (NGOs) in the region.

According to MBS statistics in FY15, just under 1,000,000 occasions of service were delivered across the GCPHN region
reflected in the following table:
Figure 11 MBS statistics, GCPHN region and National, FY15
GCPHN Services
GCPHN
MBS number of services
FY15
GCPHN
Number of patients
GCPHN
Rate
National
comparator
Psychiatrist 242,514 38,873 6.24 6.34
Psychologist 169,297 39,212 4.32 4.55
General Practitioner 254,844 151,007 1.69 1.74
Other Allied health Services 280,798 64,412 4.36 4.30
TOTALS 947,453 293,504
Our rates of services per patient were generally less that the national comparator, except for Other Allied Health Services
which was slightly higher. Again, this data does not account for services delivered through Gold Coast Hospital and
Health Service, private health insurance providers and the many NGOs in the region.
Looking at 2011 Australian Bureau of Statistics (ABS) analysis of MBS data, the rate of people accessing any MBS
subsidised mental health-related services in the GCPHN region was slightly higher than the National rate.
Figure 12 Analysis of MBS data, GCPHN region and National, 2011
Persons accessing any MBS subsidised mental health
related service
GCPHN
rate
National
rate
Population proportions 8.7% 7.2%
While the number of patients receiving treatment under the MBS and the number of services delivered has been
increasing over recent years, the number of services per patient has been decreasing.

Figure 13 MBS statistics services and patients by service type
Type of Service Period
GCPHN
Services
GCPHN
Patients
GCPHN
Service per
patient
National
Service per
patient
Regional key points
Clinical
psychologist
2011-12 to
2014-15
43%
Increase
56%
Increase
8%
Decrease
7%
Decrease
Highest patient growth rates for
people accessing clinical
psychologist services were ages
12 to 24 and 25 to 64.
Decrease in patient numbers in
region Nerang ages 12-24 which
was against the overall growth
trend of the age group.
Significant increase in patient
numbers during period 2013-15
for ages 65 and under in region
Ormeau-Oxenford.
General
Practitioner
(services
relating to
mental health)
2011-12 to
2014-15
25%
Increase
31%
Increase
4%
Decrease
1%
Decrease
Growth across all age groups
increased over period 2011-2015,
particularly in region Ormeau-
Oxenford ages 0-11 and 12-24.
Lowest coverage during period
2014-15 in region Nerang and
Ormeau-Oxenford whilst the
highest service coverage was in
region Coolangatta.
Other allied
health services
and patients
(services
relating to
mental health)
2011-12 to
2014-15
9%
Increase
21%
Increase
10%
Decrease
7%
Decrease
Highest patient growth rates for
people accessing other allied
health group were ages 0-11 and
12-24 in the region Ormeau-
Oxenford.
Growth in patient numbers were
high in regions, Broadbeach-
Burleigh, Gold Coast North and
Southport for ages 25-64.
Role of General Practice in mental health
Mental health treatment plans are for patients suffering from mental health conditions who would benefit from a
structured approach to the management of their needs. In 2013-2014, the aged standardized rate of people on mental
health treatment plans in the GCPHN region was 5,596 per 100,000 residents. This was 33% higher than the national
standardized rate per 100,000 residents of 4,207.
A number of data sets reinforce the role of the General Practitioner as a key service provider and point of contact for
people with mental health issues. In the GCPHN region as of July 2016, there were 791 registered General Practitioners
across a total of 175 general practices.
The GCPHN collects de-identified data from just under half of the general practices in the region (that is from 82 general
practices) around the demographics of the patients they treat on a month by month basis. This data therefore provides a
partial representation of the GCPHN region’s population.
According to the aggregation of this general practice data, as of 29 June 2016, there were 57,815 patients in the GCPHN
region who were visiting General Practitioners for a mental health issue. More women visit their General Practitioner for
mental health reasons than men, with 37,408 female patients in June 2016 compared to 20,333 male patients. For both

men and women, the most common age cohort, were people aged 40 to 44. There were 73 patients who were not
placed in either the male or female category.
Over 66% of patients had visited a General Practitioner within the last six months, while 80% said they had visited a
General Practitioner in the last 12 months. Figure 14 shows the distribution of patients as at June 2016 by duration since
they have last visited a General Practitioner.
Figure 14 Number of patients by duration since their last General Practitioner visit, June 2016
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
< 6mths 6-<12mths 12-<15mths 15-<24mths 24-<30mths 30-<36mths >=36mths
Numberofpatientswhohave
visitedtheGP

3.Mental Health
3.1 Youth (including children)
Approximately 560,000 children and adolescents are estimated to have mental illness and one in four young Australians
aged 16-24 years will experience mental illness in any given year. Three quarters of all mental illness manifests itself in
people under the age of 25. Intervention early in life and at an early stage of illness can reduce the duration and impact
of mental illness. Services that recognise the significance of family and social support and functional recovery are
particularly important for young people. There are particular considerations for young people with, or at risk of, severe
illness. These include differences in the needs of young people and the relevant skills and appropriate service delivery
models to meet these needs. A range of models may be needed to address the diverse clinical needs of young people
with severe mental illness, as a one size fits all approach is unlikely to be appropriate. In line with a stepped care model,
there is likely to be a need to support region-specific, cross sectoral approaches to early intervention for young people
with, or at risk of mental illness (including those with severe mental illness who are being managed in primary care) and
implementation of an equitable and integrated approach to primary mental health services for this population group.
Mental health services specifically for children aim to increase overall community access to evidence-based early
intervention to reduce the prevalence and impact of mental illness. There is evidence to demonstrate that early
intervention in both management of the mental illness and functional development/recovery for children and young
people can have a significant impact on a wide range of outcomes.
While GCPHN generally defines children as 0-14 and youth as 15-25 years, as age and other access/eligibility criteria varies
greatly across service providers and individual programs it is not possible to consider the age cohorts discreetly.
3.1.1 Prevalence, service usage and other data.
Findings from the 2007 National Survey of Mental Health and Wellbeing (NSMHWB) suggest that in Australia,
approximately 7% of individuals aged 4 to 17 suffer from anxiety, 3% suffer from a major depressive disorder and two
percent suffer from a conduct disorder.
Assuming that the rates of mental illness in the Gold Coast are reflective to the national rates, and that the rate of
mental illness prevalence in ages 4 to 17 is similar to the rates found in children aged 5 to 14, we can estimate from the
Gold Coast’s 71,347 children aged 5 to 14 leads to an estimates of:
5,000 children with anxiety
2,140 children with major depressive disorders
And 1,427 children with conduct disorders1
The Australian Early Development Census (AEDC) is a nationwide data collection of early childhood development at the
time children commence their first year of full-time school.
Looking at the social competence and emotion maturity domains, in the GCPHN region our rates have remain steady at
rate of 14% and 15% of children who are developmentally vulnerable respectively. This is slightly lower than the
Queensland figures but slightly higher and equal to the national rate respectively.
The three SA2s within the GCPHN region that had the highest rates of children experiencing developmental vulnerability
in the social competence and emotional maturity domains fluctuated. However, the SA2 areas with the total number of
children experiencing developmental vulnerability in across both domains were Upper Coomera, Pacific Pines and
Southport. This reflects the larger populations in these areas.
1 Due to the approximations and assumption in arriving to these figures, these numbers are intended to be used as a guide only, and
do not reflect actual data gathered by GCPHN region on mental illness on the Gold Coast for these age groups.

GCPHN region administers the Access to Allied Psychological Services (ATAPS) program. Through ATAPS, patients have
been eligible for a maximum of 12 sessions per calendar year, made up of six time-limited sessions, with an option for a
further six sessions following a mental health review by the referring General Practitioner. Sessions can be with
Psychologists, Social Workers, Mental Health Nurses, Occupational Therapists and Aboriginal & Torres Strait Islander
Health Workers with specific mental health qualifications.
Following a significant promotion campaign with potential referral services, over the period July 2014 to June 2016,
ATAPS referral rates for children increased by 420%, from ten to 52 referrals per month. ATAPS services increased by
59%, over the same period.
The graph below, figure 15 shows the ATAPS child referral and service frequency over the period July 2014 to June 2016
Figure 15 ATAPS children referral and service frequency per month, GCPHN region, July 2014 to June 2016
In relation to prescriptions dispensed for anti-depressant medicines and antipsychotic medicines for people aged 17 and
under, GCPHN region had lower rates than the national rate.
Figure 16 Aged standardised rate of Pharmaceutical Benefit Scheme (PBS) dispensed for anti-depressant medicines and antipsychotic
medicines per 100,000 people aged 17 and under, GCPHN region and National, 2013-14
Aged standardized rate of Pharmaceutical Benefit Scheme
(PBS) prescriptions per 100,000 people aged 17 and under
for:
GCPHN
rate
National
rate
Anti-depressant medicines 8,021 8,048
Antipsychotic medicines 1,971 2,036
Looking at a subregional SA3 level, Broadbeach–Burleigh experienced the highest rates of prescriptions dispensed, well
exceeding the national averages, 9,408 per 100,000 people for anti-depressants and 2,485 per 100,000 people for
antipsychotic medicines.
Looking at 2011 ABS analysis of MBS data, the GCPHN rate of children aged 0-14 and youth aged 15-24 accessing any
MBS subsidised mental health-related services, was slightly higher than the National rate.
Figure 17 Persons accessing any MBS subsidised mental health-related service, GCPHN region and National, 2011
0
50
100
150
200
250
0
10
20
30
40
50
60
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Mar
15
Apr
15
May
15
Jun
15
Jul
15
Aug
15
Sep
15
Oct
15
Nov
15
Dec
15
Jan
16
Feb
16
Mar
16
Apr
16
May
16
Jun
16
Numberofsessions
Numberofreferrals
Referral Session

Persons accessing any MBS subsidised mental health-related
service
GCPHN
Percent (%) of population
National
Percent (%) of population
Population aged 0-14 3.8 2.9
Population aged 14-24 9.7 8.2
3.1.2 Service mapping
Figure 18 Service mapping, youth (including children)
Services Number in GCPHN region Distribution Capacity discussion
ATAPS Child (0-12)
psychological services.
41 providers registered with
ATAPS for the Child program.
Providers are across the region
but more limited in southern
Gold Coast. Last year, based on
referrals specific effort was
made to recruit additional
providers in the Northern Gold
Coast.
Community and Gold Coast
Hospital and Health Services
providing mental health care
for youth and children are
clustered in Robina and
Southport with one located in
Burleigh and some outreach.
The majority of child and youth
mental health services focus
on ages 12-25 with eligibility
cut offs varying within this age
bracket.
Mental health services for
children aged 0-12 are very
limited. While a mix of mild to
moderate and severe and
complex providers exist,
eligibility requirements limit
access.
The services delivered by the
Gold Coast Hospital and Health
Services are largely located in
Robina and Southport.
Headspace (12-25 years)
general practice services,
psychological, psychiatry,
Dietetics, Vocation/educational
support, family and peer
support, home based care.
1 on the Gold Coast.
Neighbouring facilities in
Tweed Heads to the south and
Meadowbrook to the north.
Southport, potential for
southern GC to access
Headspace in Tweed Heads,
northern GC residents may
access Meadowbrook service.
Headspace Youth Early
Psychosis Program (12-25
years) psychiatry, psychological
, group, family and peer
support, case management,
community education.
(hYEPP)
1 on the Gold Coast.
Neighbouring facilities in
Meadowbrook to the north.
Hub and spoke model - Hub is
headspace Southport with
spoke being at Meadowbrook
(which is located in south of
Brisbane). Also accessible via
outreach.
e-mental health services. e-headspace target to youth. Online Services. Public
knowledge of these services
would drive uptake/demand.
HHS Inpatient services (ages 0-
25, with age and other
access/eligibility criteria
varying across
programs/services).
3 (Robina has two inpatient
units, child and youth (8 beds)
and Acute Young Adult aged
18-25, Southport has one
Acute Adult unit which caters
to ages 16-65.
2 in Robina, 1 in Southport.
HHS Community services (ages
0-25, with age and other
access/eligibility criteria
varying across
programs/services).
8 (Child and Youth Mental
Health Service (CYMHS), Evolve
Therapeutic Services, Child and
Youth Access, perinatal Infant
mental health, Early Psychosis,
Continuing Care Teams (18+),
Eating Disorder Service (18+),
Acute Care Treatment team
(18+).
2 CYMHS clinics (Robina and
Southport), Early Psychosis
(Robina), rest outreach.
Community based mental
health NGO services (majority
focus on ages 12 -25 with age
and other access/eligibility
criteria varying within this, 2
services cater to ages 0-12)
(predominantly facilitator and
service coordination and
counselling).
5 separate NGO providers with
programs/services specifically
for youth mental health.
1 in Southport, 1 in Burleigh,
remainder are outreach to all
of Gold Coast.

Community NGO services,
(predominantly counselling
and referral services).
8 NGO providers who provide
counselling services or refer
into specific youth mental
health services.
3 in Southport, 2 in Arundel, 1
in Labrador, 1 in Miami, 1 in
Robina, 1 in Burleigh (9 listed
as one NGO has 2 locations).
3.1.3 Consultation
Children
Service Provider Consultation
The findings from the Deep Dive consultation provide an opportunity to have firsthand knowledge about the issues that
affect children on the Gold Coast. The urgency of issues for children falls on a continuum that relates to the care they
receive as children. The following statements come from the staff of community based organisations that care for the
children whose significant others have mental health needs. The comments have been edited for sense making but
represent the current picture for children that reside in the catchment area of the Gold Coast.
Services and support for children who are undergoing gender transitioning or who identify early as LGBTIQAP+
are sparse. The HHS provides endocrine medical support with referral to Children’s Health Queensland in
Brisbane but local psychosocial support is difficult to find.
Family re-unification programs for children with child safety issues whose parents have mental health and AOD
needs are managed by community based agencies but this work is specialised and time consuming.
Falling into the hard to reach category are infants / children whose mother is affected by undiagnosed post-
natal depression. Consultation indicates the stigma of not being a good mother and limited outreach options
prevents some from accessing support. General Practice and community midwifery services are well placed to
play an important role in identifying perinatal depression as they are key contact points for this vulnerable
target group.
Risk groups include but are not restricted to those who are geographically isolated and poorly serviced by public
transport suburbs of the northern corridor.
There is an increase in complexity and/or acuity of presentations to school guidance officers and school
counsellors. Counselling services for children are managed by the Child and Youth Mental Health Service
(CYMHS) but they have to be acute enough to be accepted into the service. If children can access appropriate
therapy by the time they are seven they do better in the long term. The Complex Needs Assessment panel for <
10s has been defunded but is still running with increasing demand for the service.
Spikes in presentations to services occur for early intervention and therapeutic services between the ages of 10-
17 and 11-14 and these children can fall through the gaps as they don’t easily fit eligibility criteria..
The school system has been identified as a place where education and health staff (mental health nurses and
school based health nurses) could work together to identify and intervene for early identification of children at
risk for example to identify when parents have mental health issues and, or AOD use needs.
Service User Consultation
Service users tended to be those that represented the population of children on the Gold Coast. Children themselves are
a hidden population in terms of providing direct feedback. The dialogue took place with the adult carers and service
providers for this group.

Consumer journey – although we didn’t map a journey of a child, all consumers interviewed reflected on the
lack of intervention when they were young, particularly from school staff who could have asked about school
absenteeism but didn’t. This would have elicited key information about their at risk status.
There is only one community based service that works with children under 12 in the mental health sector.
Consultation has identified a clear need for more services for providers working with children to refer into. This
group is particularly hard to reach if they are separated from school and are not engaged in support elsewhere.
There is limited access to family support and services are often at capacity. GCPHN has been advised that certain
services have a high acuity access criterion which is a barrier for those who are not unwell enough but need
some form of intervention.
The consumer journey mapping revealed that majority of service users that had mental health and/or alcohol
and drug abuse had experienced incidences of sexual abuse, childhood trauma, domestic violence related
experiences. There was little intervention in their journeys as young children and they identify this as a serious
barrier to their mental health and wellbeing. Prevalent in all consumer journeys was no intervention and limited
opportunities to speak out or seek help. Consumer journey mapping identified that school was often a critical
early intervention point that was missed or neglected. “If someone had asked me at school I could have gotten
help but no one asked me.” School identification or intervention about mental health issues is limited and can
be dependent on what school a child attends. More counselling for children impacted by domestic violence was
identified as a need.
Youth
Service Provider Consultation
The key themes that emerged through the consultation for youth focused on early intervention, lack of services for
youth, accessibility and more mental health education in schools.
Early intervention in schools and providing more information, education and support to staff such as school nurses was
seen as a significant need in order to identify mental health concerns in youth and those at-risk and make the
appropriate referrals. The information gathered through the consumer journey mapping supports this need as many
consumers identified school as a critical intervention point where help was required but not provided.
Service providers identified that youth accessing services are presenting with much greater complexity than previously
seen and there are limited options for services specific for this age group. These complex issues include alcohol and drug
use, housing instability, family violence and exclusion from school. Alcohol and drug treatment options are limited for
youth and there are no withdrawal management options for those under 18.
The complex needs assessment panels (CNAP) on the Gold Coast were identified as a critical piece of the service system
by providing a coordinated and multi service response for youth with the most complex needs.
Transport is a barrier for youth to get to services located across the Gold Coast as many services are located in the
Southport area and public transport can be too costly or not available for them.
Service User Consultation
Consumer journey data indicates that young people can often experience severe distress and chaos as a result of mental
health issues and AOD use and the impact of the social determinates of health on their lives. From the majority of
consultations, young people said that meeting a significant adult in their lives at the right time for them was a key factor
to mark the commencement of their recovery journey.

3.1.4 Key findings
Data indicates potential geographic areas with higher numbers of vulnerable young children (prep year) are in
the northern growth corridor areas of Upper Coomera and Pacific Pines as well as the central Southport areas
and consultation indicates service gaps in the northern growth corridor.
Broadbeach-Burleigh, Southport and Ormeau-Oxenford are highlighted areas with significantly higher than
national rates for prescribing mental health medication for those under 18.
There is a concentration of services in the Southport area including the large youth health service, Headspace.
Age and other access criteria varies across the sector and consultation and service mapping indicates that access
to services for younger children (aged zero to 14) is more difficult. This is also supported by data from the
GCPHN’s ATAPs program which saw significant increase in referrals following marketing to potential referrers.
Consultation highlighted the importance of schools as an early intervention opportunity for young people.
Services report an increase in high complexity for young service users requiring coordinated, family based and
multiple agency response.
On some indicators, the GCPHN region fairs slightly better than state and national comparators such as: lower
rates of prescriptions for antidepressant and anti-psychotic medication for under 18’s and a lower proportion of
youth suicide (Mental Health, Youth (including children) page 24).
GCPHN needs to work with stakeholders to improve regional specific data on prevalence and service usage by
children and young people for future analysis.

3.2 Indigenous (mental health and suicide)
Aboriginal and Torres Strait Islander people require access to mental health services that are joined up, integrated,
culturally appropriate and safe, and designed to holistically meet their mental health and healing needs. Mental health
plans that detail a specific Aboriginal and Torres Strait Islander component help inform what the mental health needs of
Aboriginal and Torres Strait Islander people are and how best to meet them. Services need to complement and link with
other closely connected activities, such as social and emotional wellbeing services, mental health services, suicide
prevention approaches and alcohol and other drug services. Services should be integrated across the whole mental
health system. Culturally appropriate health service providers facilitate more effective mental health service delivery and
improved mental health outcomes for Aboriginal and Torres Strait Islander people. This requires cultural awareness,
cultural respect, cultural safety and an understanding of the broader cultural determinants of health and wellbeing.
Indigenous population is based on the 2011 Census of Population and Housing question about Indigenous status where
each person is asked to identify whether they are of Aboriginal & Torres Strait Islander origin. This is based on persons by
place of usual residence.
In 2011, just over one percent of the population within the GCPHN region identified as Indigenous Australians
representing 6,350 people. This is significantly lower than the greater Queensland total of four percent. Local Indigenous
service providers report that the identified population are likely to be an underestimation.
The SA3 areas with the highest numbers of Aboriginal and Torres Strait Islander people were Ormeau-Oxenford (1,137
people), Coolangatta (840 people) and Southport (670 people).
The 2012-13 Australian Aboriginal & Torres Strait Islander Health Survey collected information on positive wellbeing and
asked people to report on feelings of happiness, calmness and peacefulness, fullness of life, and energy levels. The
survey found that most (nine-in-ten) Aboriginal & Torres Strait Islander people felt happy some, most, or all of the time.
However, the survey found that Aboriginal & Torres Strait Islander adults were almost three times more likely to feel
high or very high levels of psychological distress (in the 4 weeks before the survey) than non-Indigenous adults. This was
about 30% of people aged over 18 years. Applying this figure to the Gold Coast’s 4,969 Aboriginal and Torres Strait
Islander people, aged over 18 in 2011, leads to an estimate of 1,490 people.
In the two years to June 2013, the hospitalisation rate for mental health issues for Aboriginal and Torres Strait Islander
males was 2.3 times the rate of their non-Indigenous males, and the rate for Aboriginal and Torres Strait Islander females
was 1.7 times the rate for non-Indigenous females.
In 2010, suicide accounted for 4.2% of registered deaths of Aboriginal and Torres Strait Islander peoples (NSW, Qld, WA,
SA and NT combined). After adjusting for the different age profiles of the two populations, the suicide rate or Aboriginal
and Torres Strait Islander peoples was 2.6 times the rate for non-Indigenous Australians. However it should be noted that
there have been significant peaks and clusters of suicides in some regions across the country, particularly those with
significant remote populations and therefore would not be appropriate to apply this rate to the Gold Coast population.
(De Leo et al, 2011).
Over the period July 2014 to June 2016, ATAPS referral rates for Aboriginal and Torres Strait Islander individuals has been
quite small and fluctuated greatly. Figure 19 shows the ATAPS Aboriginal and Torres Strait Islander referral and service
frequency over the period July 2014 to June 2016.

Figure 19 ATAPS Aboriginal and Torres Strait Islander referral and service frequency per month, GCPHN region, July 2014 to June 2016
For many Aboriginal and Torres Strait Islander people in the community, being able to access culturally safe and
competent health care is key to the accessibility and effectiveness of health services: The visible presence of Indigenous
staff members (such as Aboriginal Health Workers) has been demonstrated to help manage the risk of services
unintentionally alienating Indigenous clients.
Based on 2014 workforce data there very small numbers of clinicians who identified as Aboriginal and Torres Strait
Islander people as noted in figure 20.
Figure 20 Number of clinicians who identified as Aboriginal and Torres Strait Islander, GCPHN region and National, 2014
Type of Service
GCPHN
total number of clinicians
GCPHN
clinicians who identified as
Aboriginal and Torres Strait
Islander
National
clinicians who identified as
Islander
General Practitioners 687 1% 0.5%
Psychiatrists 68 0% 0.4%
Psychologists 553 0.9% 0.6%
Figure 21 Service mapping, Indigenous (mental health and suicide)
ATAPS psychological services -
Islander Social and Emotional
Wellbeing service.
Of the 67 ATAPS providers
(2016-17), 19 are contracted to
provide Aboriginal and Torres
Strait Islander Social and
Emotional Wellbeing Services.
16 providers have completed
cultural
awareness/competence
training.
Coast.
There are limited mental
health services on the Gold
Coast that are specifically for
Islander (A&TSI) people.
While many service providers
identify A&TSI people as a
target group within their
0
5
10
15
20
25
30
35
0
1
2
3
4
5
6
7
8
9
10
Jul 14 Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Mar
15
Apr
15
May
15
Jun
15
Jul 15 Aug
15
Sep
15
Oct
15
Nov
15
Dec
15
Jan
16
Feb
16
Mar
16
Apr
16
May
16
Jun
16
Numberofsessions
Numberofreferrals
Referral Session

e-mental health services. AIMhi Stay Strong App. Online Services. Public and
health professional knowledge
of these services would drive
uptake/demand.
broader programs, only the
Gold Coast Aboriginal Medical
Service (AMS) and Gold Coast
Health offer specific
Indigenous services.
The AMS has expressed a
strong desire to have a Mental
Health Nurse onsite.
The Aboriginal and Torres
Strait Islander Health service
(Gold Coast Health) deliver one
Indigenous specific mental
health and AOD program
providing supported access for
Indigenous people to
mainstream mental health and
AOD services.
HHS - programs that are
specifically for Indigenous people
(focus is on supporting access to
mainstream services).
2 (Aboriginal and Torres Strait
Islander Health & Yan-
Coorara).
Palm Beach and outreach.
Service - counselling, psychology
and General Practitioners.
1 3 clinics, 1 in Bilinga, 1 in
Miami and 1 in Oxenford. No
clinic in South Western area.
Partners In Recovery (PIR) -
service coordination/facilitation
program.
There are 2 part-time PIR
workers who identify as
Indigenous.
Program is outreach.
3.2.3 Consultation
Service provider consultation
The consultation with service providers identified that there is a clear need for capacity building to ensure cultural
capability exists in all mental health services. Wrap around care and more formalised care coordination and case
management as well as support worker options need to be available for Aboriginal and Torres Strait Islander service
users. This best promotes client satisfaction and engagement in their care. A holistic approach, outreach models, specific
Aboriginal and Torres Strait Islander workers that support mainstream services, and establishing strong relationships
between mainstream and Aboriginal and Torres Strait Islander services were identified as essential elements to ensure
this client group benefit from effective and trusted referral pathways. The limited presence of Aboriginal and Torres
Strait Islander workers in the region was a key point throughout the consultation. Particularly the need was identified for
an Aboriginal and Torres Strait Islander worker that is skilled in providing suicide prevention.
Service user consultation
Service users stated that enhancing the Aboriginal and Torres Strait Islander workforce to enable workers to provide care
coordination and specialist mental health services such as suicide support would be received positively. Accordingly,
feedback also suggested that service user satisfaction could be improved through increasing the coordination of services
by using established, well-developed and trusted pathways to support client referrals into culturally appropriate services.
Likewise client satisfaction could also be improved by increasing the cultural competency of mainstream services to
safely and effectively work with Aboriginal and Torres Strait Islander clients.
Due to unforeseen circumstances, capturing the graphically recorded consumer journey of an Aboriginal and Torres
Strait Islander client was not possible. There is also limited data or input provided through direct consultation with this
group. However feedback did identify that stigma and the “shame factor” can prevent people in this group seeking help.
There are some groups on the Gold Coast that provide soft entry points for Aboriginal and Torres Strait Islander men and
it is reported that these are working effectively and have the potential to be expanded.

3.2.4 Key findings
Gold Coast has a relatively small Indigenous population with higher density in Coolangatta, Nerang, Ormeau-
Oxenford and Southport.
There are limited Aboriginal and Torres Strait Islander specific mental health services and workers; cultural
needs are not well met by mainstream service providers.
Uptake of the dedicated ATAPS Aboriginal and Torres Strait Islander service is quite low, varying between 1 – 9
referrals a month over the last two years.
There can be stigma associated with Aboriginal and Torres Strait Islander people seeking treatment, and for men
there can be “shame” associated with accessing services.
Mens’ groups in the north and south of the region are engaging Aboriginal and Torres Strait Islander men well
and could be expanded on.

3.3 Suicide prevention
Suicide prevention is a complex issue. Causes of suicide ideation and behaviour can stem from a complex mix of factors
such as adverse life events, trauma, social and geographical isolation, socio-economic disadvantage, mental and physical
health, lack of support structures and individual levels of resilience.
As part of its response to the National Mental Health Commission’s Review of Mental Health Programmes and Services,
the Australian Government has outlined a renewed approach to suicide prevention to be implemented through the new
National Suicide Prevention Strategy. The new Strategy involves the following four approaches:
A systems-based regional approach to suicide prevention led by Primary Health Networks (PHNs) in partnership
with HHSs and other local organisations
National leadership and support for whole of population level suicide prevention activity
Refocused efforts to prevent suicide in Aboriginal and Torres Strait Islander communities, taking into account
the recommendations of the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy
Joint commitment by the Australian Government and states and territories, including in the context of the Fifth
National Mental Health Plan, to prevent suicide and ensure that people who have self-harmed or attempted
suicide are given effective follow-up support
Suicide was the leading cause of death in young people in 2010 and there were a total of 569 suicide deaths (all ages) in
Queensland. The median age of death was 44 years.
In 2013/14 a total of 781 episodes of care for suicide and self-inflicted injury were recorded in Gold Coast Hospital and
Health Service, with an age standardised rate of 143/100,000. This rate was higher than the rates for the ten years 2002-
12.
Figure 22 Suicide and self-inflicted injury, Gold Coast Hospital and Health Services for all persons over 10 years, 2002-12
110
120
130
140
150
0
200
400
600
800
2002/2003
2003/2004
2004/2005
2005/2006
2006/2007
2007/2008
2008/2009
2009/2010
2010/2011
2011/2012
AgeStandardiseRateper100,000
population
CountofEpisodesofCare
Count ASR

Figure 23 Suicide and self-inflicted injury Gold Coast Hospital and Health Services for all persons over 3 years, 2011-14
The Queensland Suicide Register (QSR) is a suicide mortality database, managed by the Australian Institute for Suicide
Research and Prevention (AISRAP) and funded by the Queensland Mental Health Commission. It collates a broad range of
information about suicide deaths by Queensland residents from 1990 to present, covering a wide range of demographic,
psychosocial, psychiatric and behavioural aspects. GCPHN has considered preliminary data from the Australian Institute
for Suicide Research and Prevention based on QSR data and it will be included in this document in due course.
0
100
200
300
400
500
600
700
0to4
5to9
10to14
15to19
20to24
25to29
30to34
35to39
40to44
45to49
50to54
55to59
60to64
65to69
70to74
75to79
80to84
85plus
Agestandardisedrateper100,000
population
Age Group
Male
Female

20% of transgender Australians and 15.7% of lesbian, gay and bisexual Australians report current suicidal ideation
(thoughts). Up to 50% of transgender people have attempted suicide at least once in their lives. Same-sex attracted
Australians have up to 14 times higher rates of suicide attempts than their heterosexual peers. Rates are 6 times higher
for same-sex attracted young people (20-42% cf. 7-13%) The average age of a first suicide attempt is 16 years – often
before ‘coming out’.
Figure 27 Service mapping, suicide prevention
ATAPS psychological services -
Islander Social and Emotional
Wellbeing service.
Of the 67 ATAPS providers
(2016-17), 19 are contracted to
provide Aboriginal and Torres
Strait Islander Social and
Emotional Wellbeing Services.
16 providers have completed
cultural
awareness/competence
training.
Coast.
There are limited mental
health services on the Gold
Coast that are specifically for
Islander (A&TSI) people.
While many service providers
identify A&TSI people as a
target group within their
broader programs, only the
Service (AMS) and Gold Coast
Health offer specific
Indigenous services.
The AMS has expressed a
strong desire to have a Mental
Health Nurse onsite.
The Aboriginal and Torres
Strait Islander Health service
(Gold Coast Health) deliver one
Indigenous specific mental
health and AOD program
providing supported access for
Indigenous people to
mainstream mental health and
AOD services.
There are no specialised
suicide prevention or crisis
services for Indigenous people
on the Gold Coast although the
Acute Care Team does employ
an Indigenous Mental Health
Worker.
e-mental health services. AIMhi Stay Strong App. Online Services. Public and
health professional knowledge
of these services would drive
uptake/demand.
HHS - programs that are
specifically for Indigenous
people (focus is on supporting
access to mainstream
services).
2 (Aboriginal and Torres Strait
Islander Health & Yan-
Coorara).
Palm Beach and outreach.
Service - counselling,
psychology and General
Practitioners.
1 3 clinics, 1 in Bilinga, 1 in
Miami and 1 in Oxenford. No
clinic in South Western area.
Partners In Recovery (PIR) -
service
coordination/facilitation
program.
There are 2 part-time PIR
workers who identify as
Indigenous.
Program is outreach.

3.3.3 Consultation
Key priorities for suicide prevention identified through the service provider consultation focused on the need for
supported and inclusive discharge from hospital, connection to community, and timely discharge summary provision to
services, particularly for Aboriginal and Torres Strait Islander people. More inclusive practices that involve individuals
themselves and community service workers in the discharge planning process was identified as an area for improvement.
The capacity in our service system to assist individuals feeling at risk of self-harm who present to hospital wanting to be
admitted but whose mental health issues are not seen as serious enough was identified as a barrier. These people are
discharged without follow up currently which represents a risk to the individual when they have not received appropriate
preventative services. Early identification and upskilling for school staff was also acknowledged as an important
requirement. As was enhancing the skills of mainstream services, GPs, and clinicians to work with at risk vulnerable
populations. The limited community support systems and services available for those that have attempted suicide was
identified by community providers. Early identification of at risk people who are LGBTIQAP+ was also reported as key to
suicide prevention.
Similar feedback was also provided from service users about individuals presenting to hospital wanting want to be
admitted because they feel unsafe but being discharged because their immediate health issues are not seen as serious
enough to be admitted or remain in the acute setting. This causes further distress and there are limited community
support systems or services for those that have attempted suicide. People who have survived suicide attempts want
more support. In addition, individuals themselves are excluded from the discharge planning process at the HHS. Being
included would assist them in feeling safe and assist in their recovery journey. Service users said that the Acute Care
Team is too stringent in terms of service response due to capacity issues. People who are high need and /or at risk of
suicide are not being responded too quickly enough. There was not a specific contributor to the consumer journey for
this topic but of the people who were interviewed which was nine in total, a significant proportion had made
unsuccessful suicide attempts. The reasons cited as to why they had been unsuccessful in their attempts were that it had
been at times when the system had “worked” well and that the individual workers had demonstrated they had genuinely
cared about them as individuals in their clinical practice.
3.3.4 Key findings
While the Gold Coast suicide rate is lower than state and national rates, the rate of episodes of care for patients
admitted to hospital for suicide and self-inflicted injury has been increasing over recent years.
Gold Coast data indicates that men account for around 70% of suicides, and 35-54 year age groups experience
the highest number of suicides; hanging is the most common method.
National data clearly indicates the LGBTIQAP+ community is particularly vulnerable.
There is value in ensuring an understanding of the warning signs of suicide in General Practice and community
services.
The interface with acute services remains problematic, including: a lack of appropriate referrals when patients
seek help who are not severe enough to meet admission eligibility; limited collaborative discharge planning and
discharge information; discharge information may not always be received in a timely way by the usual GP.
While consultation indicates that there is limited availability of dedicated community support, the ATAPS suicide
referral numbers remain quite small.

3.4 Low intensity services
Low intensity mental health services aim to target the most appropriate psychological interventions to people with or at
risk of developing mild mental illness. These services are developed or commissioned at the local level to provide low
intensity mental health services. Defining target populations, educating consumers and providers and developing low
intensity service models together with referral pathways and service parameters will contribute to improved outcomes
for a wide group of consumers. In essence low intensity mental health services target lower intensity mental health
needs, within a stepped care approach. This enables the provision of an efficient and less costly alternative to higher cost
psychological services that are available through programs such as Better Access and other primary mental health care
services.
Characteristics of low intensity services are:
Evidence based intervention (e.g. cognitive behaviour therapy (CBT) to people with, or at risk of, mild mental
illness (primarily anxiety and/or depressive disorders)
Provision of a high quality service that people can access easily and directly, with or without needing a referral,
while noting that it is best practice to involve a GP in overall health and mental health care
A variety of delivery formats (e.g. individual, group, telephone and web-based services, face-to-face, and
combinations of modalities)
Offers the right frequency and volume of service to meet the needs of people with, or at risk of, mild mental
illness (e.g. the right number of occasions of service at the right time, noting that services should be delivered in
a time-limited manner, rather than as an ongoing service)
Drawn from a broad workforce, whilst ensuring workforce skills, qualifications and supervision arrangements
are appropriate for the level of service
Using the estimated annual distribution of mental ill-health in Australia (see ‘Overview of mental health on the Gold
Coast, page 18), leads to an estimate of around 77,000 Gold Coast residents with mild to moderate mental illness.
Based on 2014-2015 MBS data, there are only 8 clinical psychologists who claimed for group therapy sessions (6-10
patients) compared to 142 clinical psychologists who claimed for one-on-one sessions. In addition 8 psychologists
claimed for group therapy sessions compared to 242 who claimed for one-on-one sessions.
Mental health treatment plans are for patients with mental health conditions such as anxiety, stress or depression, who
would benefit from a structured approach to the management of their needs. In 2013-2014, the aged standardized rate
of people on mental health treatment plans in the GCPHN region was 5,596 per 100,000 residents. This was 33% higher
than the national standardized rate per 100,000 residents of 4,207.
On the SA3 level, all areas were above the national average of 4,207. The area with the highest number of age
standardized mental health treatment plans per 100,000 residents was Gold Coast Hinterland, with 6,522. The lowest of
the GCPHN region was Robina, with 5,007 per 100,000 residents.
Figure 28 shows the large variation between the GCPHN region and national rates of mental health treatment plans per
100,000 residents.

Figure 28 MBS-funded services for mental health treatment plans by General Practitioners, 2013-14
The reasons behind the high rate of mental health treatment plans is not evident from the data, however it does raise
the question of whether low intensity services may be an option for some service users.
Over the period July 2014 to June 2016, average ATAPS referrals increased by 133%, from 57 to 133 referrals per month.
Figure 29 shows the relative increases in referrals per month over the period July 2015 to June 2016 with General ATAPS
being the dominant figure. In contrast while Aboriginal and Torres Strait Islander and perinatal referrals are relatively
much less prominent in the GCPHN region. The high usage of these general psychological services reflects the high rate
of mental health care plans in the region. The increase is referrals to Child ATAPS following a significant promotion
campaign with potential referral services indicates some potential for increased access for specifically targeted groups.
Figure 29 ATAPS referral breakdown by type, GCPHN region, July 2015 to June 2016

An example of the service use of a telephone counselling service can be found in figure 30 below (please note the region
for this data includes some areas adjacent to but outside the GCPHN region).
Figure 30 Number of Gold Coast regional calls received including locations, gender and reasons, Beyond Blue data, 2015
When
Number
of calls
% Gender % Who % Reason %
Jan-Dec
2015
1,630 Benowa/Surfers Paradise 16.4 Female 63.6 Self 77.4 Abuse & Trauma 2.1
Southport/Laborador 10.7 Male 31.3 Adjustment & Loss 3.6
Beenleigh 9.8 Anxiety 17.6
Pacific Pines/Nerang 9.2 Depression 26.5
Family & Relationships 14.7
Health & Disability 3.1
Practical Help 11.4
Pregnancy & Early Parenthood 1.1
Problem Behaviour 6.8
Self & Community 4.6
Suicide Related 8.6
Access to online low intensity service options may still be limited for some due to limited access to the internet. In 2011,
the number of occupied private dwellings that had no Internet connections in the GCPHN region was 15%, lower than
the state average of 18%. The highest rate of residents occupying private dwellings without internet connections was
Coolangatta experiencing a rate of 21%. (Please note that since 2011 it is expected that internet connectivity is likely to
have increased significantly)
Figure 31 Service mapping, low intensity services
Crisis helplines.
4 national (life line, suicide
call-back service, men's line,
kids helpline), 1 state (13
health), 1 local (
1300 MH call).
24hour telephone services.
Public knowledge of these
services would drive
uptake/demand.
Due to the paucity of
service information, it is
unclear if there are
significant capacity issues
with telephone services.
Issues may arise during peak
periods of call volumes and
web activity.
Comparatively to one on
one sessions, group
psychological therapy
sessions are significantly
lower. Group sessions are
conducted more frequently
by psychologists than
clinical psychologists.
HHS crisis helpline.
1 (13 MH CALL for the Acute
Care Treatment Team).
ACT team telephone service
available 24hrs.
Counselling helplines and websites.
10 all national (men's line,
Veterans and veterans
families counselling service,
Qlife, CAN, Carers Australia,
eheadspace, 1800 Respect,
Relationships Australia,
Counselling online, Child
abuse preventions service).
Online and telephone
services. Public knowledge
of these services and
connectivity capacity would
drive uptake/demand.
Information and referral helplines and
websites.
9 all national
(MindHealthConnect, Mi
networks, SANE Australia,
beyond blue, ReachOut.com,
R U Ok?, Black Dog Institute,
Mental Health Online,
Commonwealth Health
Website).
Online and telephone
services. Public knowledge
of these services and
eTherapy.
57 (online programs
recommended through
MindHealth Connect to
promote eTherapy and self-
care).
Online. Public knowledge of
these services and

3.4.3 Consultation
The negative effect of stigma and discrimination attached to a disclosure of a mental health need can be a
powerful predictor of the success of treatment. Getting the right treatment at the right time can be a way of
getting the most out of a low intensity service. Delay in acknowledging need and seeking treatment combined
with stigma and discrimination could contribute to poor client outcomes.
The stepped model of care characterised by the Step up Step down approach works well for clients as they are
not constrained by having to keep going with a treatment mode if it is not working for them. Conversely if
clients progress rapidly along the treatment continuum they can move onto the next part of the patient journey
without experiencing the frustration of being “stuck” in a treatment approach.
The ability of the GP to maintain an awareness of local services and confidently refer clients has a significant
positive impact on recovery. It means that the care of the GP can be augmented with services that best fit the
needs of the client. Examples are community based self-help groups and soft entry e-services that use activities
to engage clients and build skills and confidence.
If GPs know about online, self-help, low intensity services, it can assist the recovery journey.
Balanced against service provider feedback, a comment received from a GP is - “if patients are able to articulate
what their needs are this is associated with a level of satisfaction, but sometimes they don’t want what is
offered so it is difficult to find the most appropriate solution or referral pathway”.
Service users report that the identification and development of flexible evidence based services, support groups and
group sessions would add value to existing available options. Additionally, a campaign to inform General Practice about
the services available would add value for consumers. Digital mental health services do fulfil a need for some consumers,
and effectively developed pathway can increase accessibility to evidence based electronic services for some consumers.
No consumer journey was completed for the low intensity services group.
3.4.4 Key findings
While there are a broad range of quality online and telephone services (eMH services) available for people with
low acuity mental health issues, there is very limited local data on the number and coverage of “counsellors”
and evidence based support groups and group sessions of psychological support.
There are limited integration of eMH services as complementary service options into primary health care service
delivery.
Consultation indicates effective early intervention can prevent deterioration but there are limited soft entry
point models (coaching, peer-support, wellness focussed that focus on social and community connectedness).
From a client perspective, a significant positive impact on recovery can be gained by General Practitioners
referring services that fit the needs of the client. For example, treatment options can be augmented through the
use of community based self-help groups and soft entry services that use activities to engage clients and build
their skills and confidence.

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