Indigenous Australians' access to NSP services clearly depends to a large extent on the nature and quality of those services overall. Whether IDUs are Indigenous or not, their effective access to NSP services depends on basic issues such as the number and location of services, their hours of operation, and worker attitudes and skills.
This section of the report discusses what might be called generic enablers and barriers that are potentially relevant to all IDUs; section 3.2 then focuses on issues that are likely to be particularly relevant or significant from an Indigenous perspective27.
3.1.1 Hours of operation
3.1.3 Design and layout
3.1.4 Staff attitudes
3.1.5 Range of services offered
3.1.6 Supplies and cost
3.1.7 Legal and policing issues
3.1.1 Hours of operationThe hours during which clean injecting equipment can be obtained vary from place to place and from one type of outlet to another. Hours of operation among primary NSP outlets vary to some extent, but 9-to-5 Monday-to-Friday operation is common28. This is also true of many secondary outlets other than hospitals. Mobile services, by their nature, are available in particular locations at particular times of the day or week, while other types of outreach service may operate very flexibly in this regard. Stakeholders interviewed during this study frequently made the point that since a lot of drug use occurs at night and over the weekend, the limited availability of NSP services after hours is a major problem. 'At night in Palmy', said a Darwin IDU, 'it's easy to get drugs' – but not a clean needle.
Where hospital Emergency Departments provide NSP services, these are in some cases accessible 24 hours a day, seven days a week; mostly, however, hospital services are available after hours only. Dispensing machines – available only in some States, and few in number outside New South Wales – offer 24/7 access, so long as they are in working order and are regularly restocked. Certain other fixed outlets are open long hours (for example the NSP service based at the Port Augusta Sobering Up Unit, which operates 24 hours six days a week, or the Health Information Exchange in St Kilda, Melbourne, which is open until 11pm seven days a week). Opening hours of community pharmacies vary, but in numbers of areas pharmacies offer the only after-hours or weekend source of clean injecting equipment29.
In Mildura the NSP service at the Community Health Centre is open 9-5 Monday to Friday. Outside these hours injecting equipment can be bought from a pharmacy (open until 9pm weekday evenings and 5pm at the weekend). The local hospital does not provide any NSP service. In this situation, it was said, the NSP must try to encourage its clients to 'plan ahead' – which they may well find it difficult to do.
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3.1.2 LocationLocation and geographical accessibility of services likewise have obvious implications for all IDUs. Broadly speaking, inner-city areas tend to offer easier access to services than suburban or outer suburban locations. In country towns ease of access can vary considerably; there are generally few primary NSP services. Within a metropolitan area, clients may for reasons of anonymity prefer to go to an NSP outlet some distance from where they live; this is one reason why accessibility of the NSP site by train, tram or bus is important.
The current location and distribution of NSP services may reflect a range of historical factors, such as the identification of drug-using 'hotspots' at a particular time, the location of agencies which have been willing and able to act as secondary outlets, and the granting or withholding of Local Government planning approvals. Location of outlets may, or may not, make obvious sense in terms of the places where IDUs in general are currently most likely to be found (eg where they live or where drugs of various kinds are purchased). What is convenient for IDUs in general may often coincide with what suits Indigenous IDUs, but this is not necessarily the case. For example, at the time of this study there was no general-purpose NSP in western Sydney's Mt Druitt area, which is home to a significant Aboriginal population30. (More generally, said one health worker, there was 'a massive shortfall' in NSP services in western Sydney, and especially in the Campbelltown area.) There is no after hours access to clean needles and syringes in Palmerston, a large satellite suburb of Darwin which has a high proportion of Indigenous residents. In Taree it was noted that the Aboriginal population is concentrated on the edge of town, a long way from local NSP outlets. Both in Dubbo and Taree people commented that secondary NSPs had been relocated to sites that some Indigenous IDUs now find much less accessible.
Even if some good quality services are available in a given city or town, geographical access to these may be very uneven. In Darwin, for example, both the NTAHC primary outlet and the Clinic 34 secondary service are located in the city centre, with pharmacies providing the only NSP services in the suburban areas to the north and west.
Mobile or outreach services represent efforts to minimise locational barriers to access. However, these may be relatively costly to operate (and in some cases may be regarded as politically sensitive), and are not widespread. Nunkuwarrin Yunti in Adelaide is the only example the study team encountered of an Indigenous-specific outreach service, although at Redfern in inner Sydney REPIDU operates an outreach service that serves a largely Aboriginal clientele. The WAAC mobile service in Perth has two Aboriginal workers and in some locations serves a significant number of Indigenous clients.
The specific location or address of an NSP may pose difficulties in various ways – including visibility to passers by. Video camera surveillance may also be a cause of concern to potential clients. While the 'Dolls House' NSP outlet in Cairns was reported to offer good services, some criticised its location at the entrance to the Base Hospital as 'very exposed'. It was readily observed by hospital staff who stood outside the hospital to smoke, and it was also common for Police vehicles, as well as ambulances, to be seen in the adjacent parking area. 'It's a bit in your face'. The possibility that your car might be unregistered or that you might not have a current driving licence were other reasons for not wanting to attract Police attention. Concern about being seen using the service was said to be even greater issue among Indigenous IDUs because the Indigenous community was relatively small and close-knit. Whether for these reasons or otherwise, it was reported that Indigenous use of the Dolls House was low compared to other NSP services in Cairns – and that there were very few female Indigenous clients.
Some stakeholders discussed issues relating to the location of NSP outlets relative to other services. In particular, the point was made that IDUs may not feel comfortable accessing an NSP that is physically (or possibly administratively) close to a methadone program or other drug and alcohol service that they may be using. In Taree, for example, there was comment on methadone and NSW services being located close to each other. In another town visited by the study team the NSP had been moved out of the premises occupied by the Drug and Alcohol service and its methadone program, on the basis that these were not compatible services. The NSP at Blacktown in Sydney's western suburbs was described as located close to the methadone clinic where there is a uniformed security guard. This was said to be something of 'a turnoff' for new clients – especially young people for whom making a first visit to an NSP is intimidating enough in any event31.
3.1.3 Design and layoutPrivacy and anonymity are relevant issues within an NSP site as well as outside. Potential clients may be reluctant to use a secondary outlet where the NSP service is set up in such a way that 'everybody knows what you're there for'. Some service providers have accordingly organised their premises so that NSP clients are able to access the service without going through the main entrance used by other clients or visitors. The Nunkuwarrin Yunti health service fixed site in Adelaide, for example, has a separate room for NSP use; so too does the ATODs service in Cairns. In Mildura the secondary NSP operates from a 'Privacy Alcove' opening off the Reception area of the Community Health Centre – the best arrangement that could be achieved in an existing building; injecting equipment is provided 'discreetly' in a black plastic bag.
As noted above, the use of security cameras, for instance at hospitals, can also raise issues for IDUs. It was pointed out in Taree that a sign at the Community Health Centre notifies people that they are being filmed.Top of page
3.1.4 Staff attitudesDiscussions both with workers and with IDUs made it very clear that staff attitudes and behaviour can either enhance or undermine access to NSP services. In a word, clients are likely to be 'turned off' by what they see as unfriendly, judgemental or – for Indigenous clients – racist treatment. Some users, for example, cite unfriendly staff attitudes as a reason they are reluctant to purchase needles and syringes from community pharmacies, or to access after-hours services at hospital Emergency Departments.
In some locations the point was made that the quality of a secondary service depends to a significant extent on the attitudes and motivation of the individual responsible for coordinating the service, and on the extent to which he or she is supported by others 'higher up'. It was also noted – for example in Wellington – that awareness and attitudes among hospital nursing or clerical staff can vary greatly from person to person.
The use of trained peer workers or educators was referred to by a number of stakeholders as a way of facilitating good communication and rapport with clients.
3.1.5 Range of services offeredSome NSP outlets offer, or are associated with, various additional facilities or services which can make them more attractive or useful to clients. These can include relevant health or counselling services available on-site or close by, or 'drop-in' facilities such as somewhere to sit and talk, have a cup of coffee or something to eat, make phone calls or take a shower.
COAG funding for enhanced services has been used at South Court Primary Care in Kingswood (western Sydney) to establish a multidisciplinary team offering a range of services. The clinic is under the supervision of Sexual Health. Apart from NSP services, it offers wound care, blood tests, hepatitis vaccinations, dispensing of basic medications, referrals, counselling, a visiting sexual health worker, facilities to make 'a cuppa' and toast, use of a telephone and photocopier, and also a supply of second-hand clothing which is said to be very popular with clients. An Aboriginal IDU described this centre as offering her welcome 'time out' and some friendly company. As one staff member saw it, the nature of the service provided at South Court Primary Care considerably increases clients' access to other health services. This breadth of service was seen as particularly valuable for more marginalised or disadvantaged people, including many Indigenous clients. Existing clients commonly bring friends or acquaintances in as new clients, it was said. Having professionally qualified staff in-house – for example a nurse and a social worker – was also said to give an NSP like this some 'weight' within the broader health system. (It was frequently observed that NSPs tend to be marginalised or undervalued by other health professionals or agencies: 'NSPs are certainly stigmatised by other people in the health system'.)
The MINE service in inner-suburban Melbourne provides another example of an enhanced service, which itself offers drop-in facilities and adjoins a specialist health centre addressing IDU needs.
A Cairns stakeholder argued that a drop-in centre which provides the opportunity for a yarn, coffee or a snack gives valuable opportunities for establishing better rapport with clients and is a good service model in terms of reaching and retaining Indigenous clients. It is clear, however, that this approach (as well, of course, as being relatively costly) will not appeal to everybody: numbers of IDUs indicate that what they want is speedy access to clean equipment with minimal exposure to or interaction with anybody else.
The Connection in Canberra is not an NSP outlet, but it provides a useful example of a drop-in service provided by young Indigenous workers to offer peer support, practical assistance and information to IDUs (see Appendix B, section B6).
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3.1.6 Supplies and costInjecting equipment provided by primary and secondary outlets across Australia is normally free to the client (services operated by the WA AIDS Council and WASUA are a partial exception to this). IDUs who obtain equipment from community pharmacies or vending machines, however, generally need to pay for it. Vending machines in some jurisdictions dispense one or two needles at a cost of, say, $1-$2; machines in NSW typically dispense a pack of five needles at a cost of $2-$3. While the details vary from place to place, pharmacies typically sell a pack of 3 or 5 needles and syringes (often with additions such as swabs or sterile water) at a cost of around $5-$7. The pharmacy scheme in NSW provides for a new Fitpack to be issued free of charge when a used pack is returned.
Some of the IDUs and others consulted in this study made the point that the cost of buying sterile equipment is trivial in relation to the cost of drugs, or in the context of looking after your health. Others saw cost as a barrier to access – especially for low-income drug users such as those dependent on a pension or benefit32. After buying drugs, said one IDU (Cairns), you may have 'not a cent over to buy a syringe'.
Consultation suggested that cost is not the only barrier or disincentive to use either of pharmacies or of vending machines. Other issues raised in relation to pharmacies included lack of privacy, possibly negative staff attitudes, and limited pharmacy coverage in terms of hours and locations. As for vending machines, the risk of the machine being empty or malfunctioning seemed if anything to cause more concern than the need to pay as such.
In western Sydney the availability to NSP clients of injecting equipment other than needles and syringes – for example swabs, sterile water, filters, disposal containers – was reported as a positive. In various other locations, also, it was argued that offering 'a good range' of injecting equipment was for some IDUs an incentive to use NSP outlets. The services provided by WAAC and WASUA in Perth, for example, offer a wide range of equipment for sale at cost recovery price.
The consultations showed that NSP outlets may vary in their attitudes to the amount of injecting equipment they issue. There were some NSP staff who said that their concern was not with clients taking too much equipment but taking too little; they were normally willing to supply relatively large numbers of needles and syringes if this was requested. The basis for supplying substantial amounts of equipment (particularly to regular clients and/or to people who had travelled from out of town) was that some people accessing the NSP were known to be doing so on behalf of friends or acquaintances who were reluctant or unable to collect for themselves. It appeared that this pattern was particularly important among Indigenous IDUs. On the other hand members of the study team met some workers (eg some of those working in community health services) who appeared to take a more restrictive approach, fearing that providing 'too much' equipment to a client might lead to some form of 'abuse', such as the client seeking to sell needles and syringes to others. Some NSP staff were not comfortable issuing injecting equipment to clients whom they knew or suspected to be dealing in drugs. However, as noted elsewhere, some IDUs report obtaining sterile equipment from dealers33.Top of page
3.1.7 Legal and policing issuesSeveral of those consulted by the study team referred to various legal issues which continued to have negative implications for safe injecting and/or effective NSP services. For example s36 of the Northern Territory's Misuse of Drugs Act was said to discourage people from keeping a supply of clean needles available.
Across Australia there have generally been agreements negotiated to the effect that Police will not operate in a way that discourages drug users from accessing NSP services. However it is still sometimes reported that, for whatever reason, there is a greater or more obvious Police presence near NSP outlets or outreach activity that compromises their capacity to function effectively. During the present study this point was raised in particular in relation to the Nunkuwarrin Yunti Indigenous outreach service in Adelaide.
3.1.8 PoliticsSince their introduction in Australia, Needle and Syringe Programs have generally been supported as an effective health measure by both major political parties. However, sensationalist media stories and opposition from some religious groups and individual politicians were described by participants in this study as ongoing threats to the provision of appropriate NSP services – both in general and at local level. Pressures of this nature can result in NSP services, and the public servants responsible for them, keeping a low profile and hesitating to seek desirable service extensions and improvements. 'We're the most vulnerable program around' and we have to be very cautious, said one NSP staff member in Sydney. As noted above, NSP services tend to see themselves as occupying a marginal or insecure position within the health system. 'The wider health system doesn't recognise the value of NSPs' (Carnarvon).
A Melbourne stakeholder made the point that some local communities and Local Government Authorities, especially in country areas, may be opposed to the establishment or maintenance of NSP services. In Taree it was claimed that proposed improvements to NSP services had been thwarted by local politics, and observations about local Councils being 'far from comfortable' with NSP services were made in some other towns.
In general, as a matter of policy, NSP services are not widely advertised or publicised. Information on where to find NSP outlets is thus spread largely by word-of-mouth. Some people have commented, for example, that out-of-town IDUs seeking clean needles may well visit places such as hospital Emergency Departments, since they do not know where to find more specialised local outlets.
27 The 'generic' barriers discussed here are broadly similar to those described in numbers of other studies and reviews on NSP services, both Australian and overseas; see for example Canadian HIV/AIDS Legal Network, Sticking Point: Barriers to Access to Needle and Syringe Programs in Canada, April 2007.
28 Exceptions include the REPIDU fixed site in inner Sydney which operates every day, and the WAAC and WASUA outlets in Perth which are open Saturday mornings.
29 That is, other than friends, dealers or other or acquaintances who may offer clean needles.
30 The only existing service in Mt Druitt is for people aged under 25.
31 NSP Policy Guidelines in NSW specifically provide that offering pharmacotherapy services should not be a barrier to providing NSP services also.
32 As previously noted, it was often suggested that groups of low-income IDUs may share their welfare benefits to purchase drugs.
33 A Californian study reported in 2007 makes the point that less restrictive policies on dispensation of needles and syringes is associated with 'increased prevalence of adequate syringe coverage among clients': Bluthenthal RN, Ridgeway G, Schell T, Anderson R, Flynn NM, Kral AH, 'Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users', Addiction 102:4, April 2007.