Transcript

Kate Steinbeck: [00:00:02] Hello, everyone, and welcome to WH&Y's webinar for November. I'm Kate Steinbeck and I will be chairing this [webinar]. Just a few housekeeping rules before we actually start. So we are the Wellbeing Health & Youth NHMRC Centre of Research Excellence in Adolescent Health. I need to acknowledge our funders and all the universities that contribute to our research program. And if you're interested in learning more about us, here is our website: https://www.why.org.au

Kate Steinbeck: [00:00:45] Before we start, I'd like to acknowledge the traditional owners of the country throughout Australia and recognise their continuing connection to land, waters and culture. And we pay our respects to their elders past, present and emerging. 

Kate Steinbeck: [00:01:01] Just a few things to remind you, your microphone will be muted and your video switched off while our speakers are presenting. At any time, you can use the chat box, which is on the top right hand of your screen, just to react to what's going on or say hello or send a comment. If you have a question, I would like you to put that question into the bottom left where we have a question box, and we'll answer those questions at the end of the presentation. I'll keep an eye on them in case we have to answer them earlier. But please be thinking of questions from the beginning because our presenters love those. 

Kate Steinbeck: [00:01:45] I'm now going to present our two presenters, both of who are actually part of the WH&Y CRE. So, it's my pleasure to first introduce Dr Sally Gibson, who has more than 25 years experience in service provision, policy development, education and research. We first met Sally when she was at New South Wales Health for seven years up to this year, where she led the implementation of the policy response to youth health and wellbeing across the state. And it was fabulous to have her with us. Sally has moved to South Australia and is now the senior adviser for mental health and wellbeing in the South Australian Department of Education. And so we're delighted to welcome Sally. Lovely to see your face again, Sally.

Kate Steinbeck: [00:02:38] And then our second presenter is Dr Dan Waller, who is a post-doctoral research fellow both at the Faculty of Health at the University of Technology in Sydney, and also with us here at the Children's Hospital at Westmead, where this broadcast comes from. Dan's research interests include implementation, science, evaluation, research and intervention, mapping the public health programs. He's currently finishing off a scoping review of Australian youth health policy, which I think you'll all find very fascinating when it's published. And so I'm handing over to Sally and to Dan. Thank you very much for joining us as our guest speakers today. 

Sally Gibson: [00:03:27] Welcome everybody. I'm going to be the first speaker. Dan is driving our slides. I’d really like to say it's a great opportunity to talk about new health policy and to do this with Dan because we come from different perspectives and it's great to do this as a tag team. So I'll be doing a little bit of scene setting, not much at the beginning, just putting the question around, does youth health policy matter? And then Dan will actually then present his research and scoping review of his methods and findings. And then I'll come back to talk a little bit about it from the perspective of a practitioner. So what I'll be presenting is really a personal opinion and reflection rather than a research-based approach. It's something I call the Gibson Wiser Approach to policy development. So that's the outline that we'll be doing today. 

Sally Gibson: [00:04:36] Clearly, all of you who are watching this, I'm sure, knows and cares about young people's health and that it matters that we need to be doing better for young people. I mean, the Lancet Commission on Adolescent Health has provided a great evidence base for us around why it matters. We know it matters to young people themselves to keep as healthy as possible as they go into adulthood. And that's all young people are trying to be, as healthy as possible, regardless of whether they have disabilities or chronic health conditions or mental health concerns as well. It's about prevention for the future, but it's also about the community. So youth health matters because we want a community that's able to contribute and be productive as well, and also about healthy future generations. And I think that epigenetics is showing us that it's really important to be able to keep as healthy as possible in order to have healthy future generations. 

Sally Gibson: [00:05:41] So, if young people's health matters, what about youth health policy, does that matter? Does it make any difference to have a policy around young people's health? And if it does, why is it so difficult to actually sometimes get those policies developed or get them implemented? So this slide shows that putting an emphasis on young people's unique needs, having responses to that is part of the argument for having a youth health policy. Young people are often underrepresented in what's spent on healthcare and what the research is. But as Dan will show, there's a lot of difference across Australia in terms of the policy approaches that are taken as well. 

Sally Gibson: [00:06:31] And so finally, before Dan speaks, and this is what I'll come back to a bit at the end of Dan's presentation, because I think we all know that policy can sound like quite a clear process. And I think particularly in health, when people are used to sometimes doing clinical policies where there can be quite a scientific approach to doing randomised controlled trials or things like that, and where the evidence base can be a bit clearer. But my experience is that doing policy is about competing discourses often, and there's a real tension between the image of what the policy design process is, and what those of us who might be in the thick of it are trying to do with that activity, actually experience. So I'll come back to some of these themes later, but now I'll pass over to Dan and he'll do a presentation on his research. Thank you. 

Dan Waller: [00:07:32] Thanks, Sally. And I'd like to reiterate that it is really nice to be able to co-present with Sally because I think we have quite different backgrounds, but quite complementary as well. So whilst Sally has a wealth of experience in the development and implementation of policy, I have a research background. I'm kind of looking at the theoretical perspective that is really kind of sitting on the outside scratching my head, trying to figure out how it all kind of fits together. 

Dan Waller: [00:08:03] Part of the work that I've been doing has been a scoping review of Australian policy. And the aim of that work was to try to determine the extent, range and nature of recent policy specific to the health and wellbeing of young people within Australia. The scope of that work was looking at prospective policies, plans, strategies, blueprints or frameworks and more interesting publications that were coming from Australian federal or state government departments that have been published from about 2008 to 2019. So what we were trying to do is find policies that were relevant to young people and were looking at their general health and wellbeing. So rather than specific policy, say on diabetes or drug use or things like that, we're looking at general health and wellbeing and also the general population. So not looking at specific groups of young people like Aboriginal or Torres Strait Islanders or youth out-of-home care - we're looking at the general health and wellbeing of young people. 

Dan Waller: [00:08:59] We had a couple of research questions for the scoping review. The first question was, what is the coverage of Australian, federal, state and territory policies specific to the general health and wellbeing of Australian young people published between 2008 and 2019, [and the second] what were the key themes that were coming out of those documents? We considered a scoping review to be the most appropriate design for this kind of research, it is the alternative to a systematic review, which is really good if you're doing exploratory research in broad topic areas, particularly if you're working in an area where there's a lot of grey literature or non research articles. So that's obviously very important for policy research where we're not having to do research designs. It allows for the qualitative analysis of these documents as well, which means that you can identify key themes that are in those publications and policies. Scoping reviews are increasing in popularity based on some of these benefits. And you can see a lot of publications coming out in recent years that have featured that methodology. 

Dan Waller: [00:10:05] Within our scoping review, we also conducted thematic analysis of the documents, identifying key themes that were within these policies. And that was done through an inductive coding approach where we had no preordained theoretical structure. We were looking at the information within those documents, coding some of that information and then building semantic themes that came from that. So this is a really nice approach to policy analysis because it kind of reduces bias. And you get to see what are the key factors and themes that are coming out of the policy documents. What are the themes that are generally across the different policies? 

Dan Waller: [00:10:43] So, to identify the policies that we were interested in, we looked at 126 government departments and agencies that we identified through government directories. The links are here https://www.directory.gov.au/departments-and-agencies. And we also looked at some peak policy websites and peak bodies as well. We looked at the Australian Policy Observatory, the Australian Association for Adolescent Health, the Student Wellbeing Hub and Youthpolicy.org. Once we'd identified the websites that we wanted to search, there was a two-step process. The first step was to navigate to a publications page if there was one, and we tried to identify any relevant documents there. And then the second step was to use the website search tool. So we had a lot of keyword search terms that we entered into the search tool and those were: youth, young, teen, child, adolescent and health, wellbeing or risk or planned policy strategy, blueprint or framework. So we're trying to identify policies and applications that were relevant. 

Dan Waller: [00:11:44] For the inclusion criteria for our scoping review, the publication needed to be a prospective planned policy strategy, blueprint or framework, it needed to be published from an Australian federal or state government department, and it had to be relevant to the general health or wellbeing of young people. So, again, we're interested in the general population of young people, and we're aiming for a policy that looks at the age group of about eight to 25 years. Importantly, we did have a few policies that came out that didn't have a specific age range that was identified, but we included those because they discussed adolescents and young adulthood. We also included any policy publications that included pediatric groups as well as adolescents and young adults as well. The documents were published from 2008 to 2019 and we also included expired or rescinded publications because they are still relevant to the policy environment over the previous years. 

Dan Waller: [00:12:43] Using this approach, we identified 12 policy publications from Australian state and territory governments. And there's some of the information about those within this slide. What you can see is there's fairly good coverage across states and territories and federal governments in regards to youth health policy. There were three national health policies, three from New South Wales, one from Victoria, one from Queensland, two from Western Australia, one from Tasmania and one from Northern Territory. Importantly, South Australia has youth policies that are in place, but they weren't specific to youth health. And the Australian Capital Territory is also in the process of developing a youth health policy. So there is still movement within this space. 

Dan Waller: [00:13:34] If we look at the timelines for these policies, what we can see is that there's actually been quite a lot of interest in youth health policy in Australia in recent years, particularly from 2018. There are actually quite a few relevant policies that are in place at the moment. And it shows that there seems to be a growing area of interest for policy. And if we look at the age groups of these policy documents, you can see that there's actually a fair bit of variation in the age groups that are being targeted as well. This shows that there is this kind of difficulty in having hard boundaries for what we define as a young person or young adult or an adolescent. So some of these policies were relevant to ten to 25 year olds or 12 to 24 year olds. And some of the policies looked at the range from pediatric to young adulthood as well. I guess this is an issue across research and other international policies as well, where it is difficult to have these boundaries. But there are potentially implications of these policies if they are tied to services that are available for young people. So it is something to be considerate of. 

Dan Waller: [00:14:45] We conducted a thematic analysis of the publications that we had and what we came up with from our analysis was these three meta themes which kind of explained the majority of the information within the publications. So the three major themes were: policy aspirations, which is what are the goals of the policy, what are we trying to achieve?policy foundations, which is how is the policy being developed? What information do we have to actually create this policy and what are those processes? And then we had policy implementation. So how are we actually going to achieve the goals that we set out to? 

Dan Waller: [00:15:24] Looking at the policy foundation theme, there were a number of sub themes within that. So we did have this issue of defining youth and trying to find hard boundaries, which is going to probably be an ongoing issue that's never really solved. If we're looking at the definitions of health, what we see is that there is actually quite a lot of increasing interest in health in regards to well-being and resilience. So we're starting to get towards this understanding of youth health that has been very important from a physical health perspective, but also from a mental wellbeing and social wellbeing and looking at social outcomes as well. So the definitions of health within youth health policy are actually broadening to have this broader understanding of wellbeing. 

Dan Waller: [00:16:09] All of the policy documents identified key health issues for young people. Some of those were obviously mental health and suicide, risk taking behaviors or drug use, sexual behaviors. And what you can see in the more recent documents is that there is a bit of a consideration of things like health and safe use of Internet exposure to pornographic content or violent content and cyberbullying. There's a few issues that are coming through in policy that weren't necessarily around 10 or 20 years ago. Interestingly, the Victorian health policy was the only policy to consider the determinants of climate change on the health of young people. It’ll be interesting to see whether that is a consideration in health policy going forward for this group. 

Dan Waller: [00:16:56] The majority of the policies did consider the socio ecological determinants of health. So there's a lot more of a focus on what are the kind of key disadvantages that are really impacting young people's health and things like access, socioeconomic status, cultural issues, these kinds of things where are the boundaries and the intersectionality that can have implications for a young person's health? And they also consider a life course approach. There is this increasing understanding that if we do intervene early, this can have a very significant impact on the health of young people in their futures. So considering a life course approach to health is really important and does seem to be considered in policy. 

Dan Waller: [00:17:37] The policies also were quite well supported by research and evidence, particularly the newer ones and a lot of the policies we've developed on the basis of quite large scale surveys and studies with young people, and consultation and co-design is increasing as well. We can see that some of these policies were developed in conjunction with a reference group of young people who were trying to identify what's important to them for youth health. There does seem to be this growing voice for the young people, which is really what WH&Y is trying to do. All of the policies had links to other policies within the broader scope of health and also the broader general health policy. There were quite a few links to education policy, for example, for young people or particular services and things like that as well. 

Dan Waller: [00:18:25] Movving on to the policy aspirations theme, what occurred was there seemed to be these quite clear goals that were across different policies. And these came out quite clearly. The three key policy aspirations were around access and equity; integration and navigation of health services and prevention; early intervention and management of conditions. That access and equity theme really did consider the socio ecological factors that are important for a person's health and really underline the importance of universal service access and start to consider things like geography and inclusiveness of services, youth friendly services, cultural competence, and things like flexible hours for people who might not be able to get to services in standard operating hours. The integration and navigation theme really emphasised the importance of integrating services and information-sharing across services. So that might be specific health services having better information sharing processes or it might be considering transition from pediatric to adult services and making sure that the young person has a very smooth journey across those. It was underlined that cross-sector collaboration is important and a number of methods for improving that and working with say education, or the Justice Department to be able to have better health for young people was underlined within that theme and there was some discussion of navigator rules for that kind of transition of care, particularly for people with chronic conditions. 

Dan Waller: [00:20:00] It was good to see that a number of the newer policies really focused on empowerment of young people trying to increase health literacy and make sure that people are understanding their health conditions and are able to navigate the health system effectively. And then in regards to prevention, early intervention and management, that was a very strong focus on public health and health promotion approaches, emphasis on early intervention to reduce risk and also reduce long term health issues and burdens of the disease, particularly again for people with chronic conditions. 

Dan Waller: [00:20:37] And then the final theme that looked at policy implementation. I guess this was probably the theme that was the least well described within the policy documents and had the most variance across the policy documents as well. There was some discussion of funding and government structures that are relevant to the policies within some documents, whereas some of the documents really didn't have very much information about that at all. There was also discussion of the infrastructure and technology that is needed for trying to achieve some of the goals that are set out in policy. And there was also discussion of the workforce and the importance of retaining and training highly skilled health staff. So looking at ways for professional development and engagement of staff and keeping those people involved.

Dan Waller: [00:21:25] The discussion of planning, monitoring and evaluation of policy again was very varied. Some of these documents had quite strong planning and monitoring frameworks in place to see how this policy is going to be implemented and evaluated and whereas some of them said, well, these are the key goals that we have and then didn't provide too much information about how we're going to get there or what kind of funding or government structures that are there to be able to support those. 

Dan Waller: [00:21:54] So, from our scoping review, we came down to three key learnings from the policies that we looked at. The first key learning was that approaches towards developing youth health policy in Australia are actually getting stronger. There is increased interest in youth health policy. There's been a lot of policy development in recent years, and these policies are moving from different deficit models of health towards a strength-based approach. So, considering wellbeing, resilience, those kinds of important factors as well as physical health. There is good recognition of socio ecological factors and intersectionality that impacts health and disadvantage. However, there is a research article that has critiqued the Australian youth health policy in this area and suggested that whilst it is identified as an issue, there has not been much policy action that has focused on this to try and reduce that entrenched inequity. Finally, there is increased research and youth participation within policy formulation, not so much implementation and the other kind of stages of policy. But we are seeing a bit of a growing voice for young people. And I guess it's really great to see the WH&Y Commission with the young people and the Consumer Health Forum Advisory Group, which is really focused on giving young people a voice, letting them tell us what's important for their health, and then having that translated into important policy and research.

Dan Waller: [00:23:30] The second key learning is that there are actually three fairly clear and unanimous policy aspirations for youth health in Australia across these policy documents. And these are: access and equity, integration and navigation of services and prevention, and early intervention and management. So these kind of serve as a pretty strong marker for us to say, well, these are the things that we need to be focusing on if we're looking towards policy development in the future or developing a blueprint for future policy implementation work in youth health. These are probably things that we want to focus on and that can also lead a research agenda. So if you're developing research themes within youth health, these are probably some pretty important things for you to look at. Interestingly, after I had conducted the analysis for this scoping review, I started to look around internationally to see what kind of goals were being promoted through other organisations. And you can see that there is this international group that is looking at similar issues. This is from the UK Royal College of Pediatrics and Child Health. And if you see their key priorities, they have very similar priorities that are outlined in Australian health policy as well. You can see reducing child health inequalities, access and equity, prioritising public health, prevention and early intervention, intervention and management, and building cross-sector services as well. So that's integration of services. Interestingly, navigation isn't necessarily picked up here, but that's probably because it's more relevant to pediatric care than these group priorities, whereas we're interested in adolescents. So navigation becomes a real issue when we're transitioning from pediatric to adult services. Nevertheless, it suggests that, again, these kinds of key themes look like something that we should be interested in for research and policy making. 

Dan Waller: [00:25:25] And then our third key learning is that the proposed methods for the implementation of Australian youth health policy recommendations are as yet unclear. So the discussion of policy implementation varies quite widely across documents. There's limited discussion of budget and governance, limited planning, monitoring and evaluation of frameworks that are developed for these policies, limited implementation plans and also limited success measures as well. There is variation, and some of these come with an implementation plan. Some have come with an implementation plan that wasn't then put into place. But there is this kind of wide variance across policies, and this isn't necessarily surprising because sometimes these policies are created without any kind of budget to support it. So it's quite difficult to say well this is how we're going to achieve our goals if there's no framework to implement those changes. This was actually identified as an issue within the Henry Review, which was a review of New South Wales health services for children, young people and families. And one of Henry's key recommendations was that all future health frameworks in New South Wales should be complemented by an implementation plan, outcome measures and monitoring of both policy implementation and policy outcomes. So this kind of speaks nicely to our findings. And our findings complement this by suggesting that this is actually a national issue. This is something across national policy that needs to be addressed. 

Dan Waller: [00:26:55] With our findings, it's important to consider the limitations of the research we had in our narrow scope where we just looked at health policy relevant to young people in general health, not specific conditions or specific populations, so we may have excluded some potentially interesting or relevant documents. However, it does provide us with a much stronger focus to see what's generally out there for young people. 

Dan Waller: [00:27:22] We conducted a thematic analysis which really indicates what is within a document or within a policy rather than what's missing. And there's limited theoretical underpinnings for this approach, which means that we can't really do any kind of hypothesis testing. We had a single researcher who did most of the coding of qualitative analysis. However, we had a research group at each stage to check the coding and contribute to the research themes. And we did no international comparisons within this particular study. However, that's something that we are interested in looking at within the future. Finally, it's a fairly time-consuming process as well. 

Dan Waller: [00:28:02] So, in conclusion, based on our findings, policy in Australia is heading in the right direction for young people and their health. However, there are numerous opportunities that remain, particularly around providing a greater voice for young people and also the implementation of policy. So the next step for me is we have this work that is under review at the moment for a publication. We'd like to look at some of the international policies and compare them and also conduct some qualitative research to try and understand these issues a bit more. As Sally said before, research can be a very straight line and suggests that everything works very easily, whereas often real policy development and implementation is working in chaos. This is a very simplified overview of how policy is working. It would be great to do some qualitative research to understand that a lot better. And then working towards this to try and get an implementation of policy and get a blueprint for advocacy and development of policy and research moving forward. 

Dan Waller: [00:29:09] Just quickly, some of the qualitative research that I'm hoping to do, that I have ethics approval for at the moment, is to talk to policy developers and policy makers about some of the issues around developing policy, and policy implementers about some of the issues about implementing these policies. Where are the bits that are missing that we could improve  upon? Trying to look at evidence makers, researchers, and how can we better move evidence findings quickly into policy so we can have a stronger evidence-based approach which is more current. And then also talking to consumers or young people and their family about what's important for them for policy. 

Dan Waller: [00.29:48] So, I'm going to be talking to policymakers quickly at first, and then we're going to be looking at some theoretical approache. Looking at some of the stages of policy, a theoretical approach that looks at advocacy, coalition frameworks, which is kind of trying to understand the actors and the processes involved and how it's a very dynamic process. Looking at some of the policy tools that we're trying to use to change people's behavior and health behaviors. And then also looking at the theory, punctuated equilibrium theory, which suggests that policy moves at a relatively gradual and steady pace until there's a big change or a societal change. And I think that Covid-19 is one of those issues where we are seeing quite a development, rapid development of policy change societally. So it'll be interesting to see what the impacts on policy development are out there. Probably most relevant to things like access and the use of technology to increase services, particularly for geographically diverse regional people and those kinds of things from all over the country. So plenty of research to go ahead. And I think I'll pass over to Sally who'll give you much more in-depth detail of some of the more spiky issues of policy development and implementation.

Sally Gibson: [00:31:12] Thanks Dan and no doubt in the future, given that you're going to be doing research interviewing policy makers, we might talk more later. And also, I'm sure there are other people who are watching this who may be good people to interview around some of those policy development processes. 

Sally Gibson: [00:31:30] I thought I'd start with what is sort of a typical policy development cycle that's often used in government. So you define a problem, then you come up with options to address that problem, then you submit it up for approval to proceed and then you implement. And hopefully we can talk about implementation plans a bit later. And then you have an evaluation and monitoring process as well. So certainly that process is a process that I have tried to follow many times, and I should say I'm talking about my experience primarily in developing the New South Wales Youth Health Framework. But prior to doing that, I also had developed HlV strategies for South Australia. So I'll be drawing on some of that experience as well.

Sally Gibson: [00:32:25] The next slide actually shows you what the experience often feels like when you're doing policy development. So practical policy making really can feel like herding cats, and I'd like to think maybe that I'm out on the horse or is that someone above me or am I one of the cats, in fact? But generally, policy making is trying to get things to at least go in some sort of coherent direction so that you can maximise impact on the areas that you are trying to make that change. But it can be really tricky. It's often different silos. So mental health doesn't talk to sexual health, doesn't talk to drug and alcohol use. You've got different strategies that deal with that. And then you've got the clinical arms and the children's hospitals and you're trying to get that all to work together. So I have to say that it can be quite challenging at times, but always interesting.

Sally Gibson: [00:33:28] I thought I'd just share some of my own views, really, and I've called it the Gibson Wiser Policy Approach, 2020 - don't go looking for it in Google Scholar, because it's not published anywhere. It's really an opportunity to name something after myself. So my Wiser approach is the typical policy development implementation process. I think the why, why are you doing a policy is really important. So when I came into New South Wales Health, there were people before me, Kate Steinbeck and others, David Bennett, Melissa Kang, and others who had been involved in developing a youth health policy for New South Wales many years ago. And that did provide a frame, a lens, an emphasis on young people, which is really important because the health system often neglects young people. But as we came forward and that ran out in 2012 or 2013, and then that was an impetus about, well, how are we going to do another one? And if we are, why are we doing it? What's it going to deliver? So my view and certainly of the stakeholders as well that we can consult with is that in the absence of having a youth health framework, those that are working on youth health in New South Wales Health really don't have any sort of legitimising document for the work they're doing. And so that's what seems to be important, that we have at least a statement of commitment to young people's health and that we update some of the latest thinking about how you might do that. But you still need to have a sort of convincing reason why, because you are within quite a crowded space of policies and frameworks that you have to justify. So when you're in government, sometimes the hardest thing is also finding out, are you doing a policy? Are you doing a guideline, are you doing a strategy? Are you doing a framework? And I can't tell you how sort of perplexing and frustrating at times it is to know what language you're using for what you're doing. 

Sally Gibson: [00:35:41] But there can be real gaps that need to be met. And obviously, looking at some of the evidence for why you're doing things is really important, but also being opportunistic about it. So in New South Wales, we had Brad Hazzard as the Health Minister, and so we certainly timed the release and development of the New South Wales Health Framework to the National Youth Health Conference to enable the Minister to show his support for young people's health. 

Sally Gibson: [00:36:17] You've got to think about what it is you can put in a framework or a policy that can actually be implemented because you need to be aspirational, as Dan said, but sometimes if you are too aspirational, then one, it won't actually get out of the Department, won't get approved. But also it might leave you with a lot of things that never get done and then questions can be asked about that. I had the experience working in HIV when there was a need or there were some people who thought strongly that there should be provision of clean needles within the correctional services system. But that was not something that we were going to get past the Health Minister. And so you end up sort of changing language to recognise the risk but you use different words like strategies to prevent harm within correctional services. And if the culture changes around you, maybe there might be some action. But you don't want to jeopardise getting a policy through sometimes for the sake of some words. But some things are so important that you really do have to advocate for that as well. I'll talk about implementation a little bit more in my next slide. 

Sally Gibson: [00:37:33] The stakeholders are really important and clearly young people are stakeholders. And for the development of the New South Wales policy, we held two consultations with young people. We actually used the research that we funded through university, through Melissa's Kang's group, so the Access Research Study Three. That provided a lot of information for us about young people's access to health care that could then go into the NSW Youth Health Framework as well. But then we also held one rural youth health policy consultation and one out in western Sydney with about 100 young people as well. The other stakeholders are the health professionals, the health managers. We made a decision, that the framework for New South Wales was going to be really just for New South Wales Health, so we weren't trying to take on what family community services were doing around the determinants or what GP's are doing, which was beyond the scope of what we could actually influence. But we did recognise that there are partnerships that are important. 

Sally Gibson: [00:38:49] I put the word encourage in my Wiser, which is something I thought about quite a lot, and I'll talk about it a bit more on the next slide. But clearly E could also stand for evidence, which is really important and how you use that. And you often use that within a narrative where it's about trying to influence and educate, but also evaluation. And I was interested to hear from Dan's presentation. My experience of evaluation of policies and frameworks has been that it has been very, very difficult. More often than not, when a policy comes to an end, and this is true for the HIV policies I was involved with, as well as the Youth Health policy, it's more a review process that takes place, mainly because an evaluation framework is often not in place for a policy. And that's also linked to some of the difficulties with resourcing around implementation. So I do, of course, think it's really important to have some agreed measures of success, but I think it is an area that we need to get quite a bit better in.

Sally Gibson: [00:39:57] I’ll just go to my next slide, which looks at the I and the E in a bit more detail. My experience of working, particularly in youth health, has been, as well as very rewarding, that implementation is really challenging, mainly because there is often very little funding and you are also often competing against other priorities. So can you show value for what the interventions are? Is it saving the system money somewhere? What's the cost benefit of what you're doing? So we may have some smaller elements where we can talk about preventing ill health in the future and the costs that will get saved. But it can be very difficult to show that if a health service reorientates about how they deliver to young people that that will actually save the health system any funds and money in the future. 

Sally Gibson: [00:40:53] I've also learned, and we did try to set this in place with the youth health framework, that you do have to make expectations clear and have some level of accountability. So what we did for the New South Wales Youth Health Framework was that we did have an annual planning and reporting process with each district and the Sydney Children's Hospital Network. And that really was so that every year they had to think about what they were doing and report back to us on what they had done. Some might say that's quite a low level amount, but it did provide an opportunity for those working on young people's health to brief their chief executives at least once or twice a year. And also, if they were wanting to do things around young people's health, they could also say, well, it's in our annual plan, we've committed to do it and we need to do it. I think leverage is really, really important when you're working on young people's health policy. And my experience is that there can be new priorities or sort of new things that come in that are really required. It can be really helpful. So New South Wales has now got a rural youth policy and that's an opportunity to promote young people's health in rural areas. Mental health is getting a lot of attention. I'm working in the area of mental health and wellbeing at the moment and clearly we are seeing some of the distress and anxiety that's happening from Covid and also, I think, some other influences on young people's mental health and wellbeing. 

Sally Gibson: [00:42:26] Just on the Covid issue, I think it is an opportunity, and I know that there's been some researchers with WH&Y who are looking at telehealth and how to deliver health care to young people through using telehealth. If you'd put a proposal up around using telehealth a year or so ago, probably it would have been quite difficult to get funding for it. Often young people don't have the chronic health conditions that people are really focusing on for telehealth. But I think Covid obviously is presenting a lot of challenges, but also a lot of opportunities about showing how to do healthcare differently, including with young people. 

Sally Gibson: [00:43:04] The other thing that we did to support the youth health policy in New South Wales was developing guidelines and training, things like doing the HEADSS psychosocial assessment, getting through New South Wales health. That was an expectation that that would happen. That can be a big gap between setting expectations and actually making it happen. But if you actually don't have it there and written that young people should have a conversation around their holistic health care, then you will never have a chance to make that influence happen. And around that, then you can also put things like training and development and even building it into the electronic medical record as well, which is what we managed to do. So there can be some good outcomes from just trying to influence the system at quite a small level.

Sally Gibson: [00:43:53] I just want to finish around the E and around implementation. So the Henry Review, quite rightly, and I was interviewed as part of the Henry Review, look, there was no visible implementation, high level plan for the new health framework. And we certainly didn't have the resources to do that. We didn't have the resources to do regular reports on it. But what I really thought was important was about encouraging and supporting those who are already engaged in youth health, and that's a lot of you. And it's where WH&Y has come from as well. The researchers, the health staff, the youth advocates, the partner agencies. And you can do that in multiple ways. And the Youthhealth Framework does have this in it and it is a tradition that was started under the previous youth health policy. Networking, making sure that people are connecting with each other, particularly those in rural areas who are often working quite alone, really around trying to put a focus on young people's health, showcasing the good work that does happen. So we did hold youth health showcases to bring people together, to give a focus on that and really make some of that work visible. And those of you who are researchers, obviously do that through publishing your findings of what you're doing and showing how you can make a difference in youth health. And I really do believe that encouragement and really supporting the champions and your allies is really important if we're going to grow a stronger base around young people's health and really make sure that people understand that it's no good just focusing on the early years in child health, we really need to keep that emphasis going into adolescent health as well. 

Sally Gibson: [00:45:41] I’ll just go to the next slide. And I just like to thank you all for listening to Dan and I. This is a photograph that was taken at Western Sydney Youth Health Policy Consultation, where we got to see the passion of young people out in western Sydney who make a difference to young people's lives. And just to emphasise that giving that focus and attention to young people's health, that youth health policies can make a difference, but clearly, it also needs a lot of effort to keep it going. Thank you. 

Kate Steinbeck: [00:46:24] We've got time for a few questions and you have a few questions that are actually already being sent through. So my first question that I'm going to read out is, and it's probably to both of you: "Covid has really demonstrated how research and policy needs to be more responsive to changing contexts. What can help us do this in the area of youth health? Do we need different partnerships, methods or even attitudes about young people as more than just consumers of health?" Quite a lot there who would like to start, Dan or Sally?

Sally Gibson: [00:47:20] Well, also, I did mention Covid, I'm not quite sure about the last bit of the question about more than consumers of health?

Kate Steinbeck: [00:47:28] Yes, I think it's probably a question. And it does come from Pip Collin in Western Sydney University, I suspect what Pip is asking about is, Is there something in the community that makes it difficult, perhaps in attitudes for policy to either be enacted or developed 

Sally Gibson: [00:47:55] Around Covid? 

Kate Steinbeck: [00:47:57] I think more generally than just Covid. I think Covid has been, as both you and Dan have mentioned, one of those sort of key events that perhaps we only have in a lifetime certainly shown, is that perhaps young people were not viewed very kindly in the Covid environment.]

Sally Gibson: [00:48:18] I mean, I think that's true, and I do think if you talk about the big H health system, there is a lot of emphasis around showing the cost benefits of what you're doing, and that can be very hard to sometimes demonstrate. And so when you're talking about often a quite healthy population, it can be really hard to get that attention on the young people's health needs. And then when you do get some attention, that's usually on those sort of factors that are the very negative ones. And we're not looking at early enough about what can be done around holistic health care to prevent things like self-harm. And I think if you look at where the worst impacts of Covid were being identified in terms of illness, it wasn't, again, in young people. So I think that's probably why there wasn't an emphasis. And in my experience there can be very tricky issues around privacy and confidentiality and how to deliver services and how do you get parental consent? And I know that there are other researchers looking at those issues, but I think it's really, as I said, a great opportunity to diversify how young people can get access to health care. I don't know if Dan wants to say anything else. 

Dan Waller: [00:49:48] Yeah, I think one of the important points that Pip made was around attitudes and how young people are perceived. And I think one of the things that is important is to make sure that we're not just doing tokenism around these kind of things. So whilst a lot of the policies are developed with some consultation of young people, it is this kind of attitude to make sure that, you know, it's not just a tick box exercise, but we actually are considering the needs of young people. So I think having that kind of broader range of people who are involved with policy development and research and things like the WH&Y Commission, having those kind of frameworks that can really promote the voice of young people is really important as well. 

Kate Steinbeck: [00:50:34] Thank you Dan and Sally. I'm going to move on to the next question. And the next one is: "Are there lessons here for child protection policy, especially given that child protection should be using a public health model?". 

Sally Gibson: [00:50:55] I've also done a bit of work in that area, and I do agree, but I do think that the child protection and wellbeing response is moving much more towards that approach now. I mean, we still hear a lot about those that are within the statutory system, but the language around the policies around it is more around well-being as well and keeping all children safe. And what are the circumstances and how do you do that? And then how do you intervene as early as possible to prevent the trajectory going into more abuse or needing to go to care? So absolutely, whoever's asked that question, I absolutely agree that the public health response to child protection is really important. I do think there's a real lack of, not a complete lack, but there should be more emphasis on the needs of adolescents. So when I was in health, I did a deep dive into files of children in residential care, and adolescents particularly were really finding big challenges getting the care they needed. And a lot of them had been in care for about 10 years. And so often the stretched system only really still goes down to the bottom, to the young years. And so by the time they get to adolescence, we all know they age out of care and often end up homeless or with other situations as well. So I agree that there are real lessons around taking a universal public health approach to child protection as well.

Kate Steinbeck: [00:52:30] Thanks, Sally. I'm going to move on to the next question, which is: "thank you for a fabulous and informative presentation. While there's an increased focus on health policy for young people, which is strength based, how do health departments plan funding the implementation and evaluation of these policies, beyond non-monetary support or collaboration with researchers?” 

Dan Waller: [00:53:12] Think that's it in a nutshell, isn't it really? I think we are at the starting point of this question and I mean, one of the key goals of some of the work at the CRE was to look at this kind of issue and ask how can we better help governments to implement policy around this area? So what I'm hoping for is to conduct this qualitative research to try and understand some of those issues in detail and then using things like the Henry Review to see where recommendations can be made to make changes. I am going to put my hand up and say I'm a researcher, I'm on the outside, I am giving a very simplified view of things. So, Sally, if you’ve got any answers? 
 

Sally Gibson: [00:53:57] No, I mean, I do think that external advocacy is important and that it can be much easier if sometimes the ministers are supportive or really understand, and I'm really aware of how much is going on in, say, New South Wales education at the moment. So there was a commitment made by the Berejiklian government for $88 million over four years to put psychologists in every secondary school. So that's not something that we have here in South Australia. I'm not aware of that. And I know that the minister of mental health recently made a commitment for 100 nurses to work across schools as well. So a lot of that's not being driven necessarily out of a government department. A lot of that is based on a commitment or passion of a particular minister. And how does that happen? I mean, that's when I think about getting ministers out to look at programs, to hear about things, that narrative captures the imagination, shows what can be done. You can really make a difference sometimes as well as then having the evidence base. But I have found in the government that it's very difficult putting out business cases, not impossible to get new money, it is possible, but it can be very difficult to do that. 

Kate Steinbeck: [00:55:31] Thank you, Sally, I'm going to finish off with a combination of a couple of questions which have been asked about the role of education and working in partnership with the Department of Education. One has asked for a comment, too, on the recent announcement in New South Wales of school health nurses in schools. And then combining that with a question that was asking, and perhaps Dan you've obviously viewed that policy, is around a memorandum of understanding between health and education when it comes to dealing with chronic illness in young people. So I guess that's a couple of questions about how we can look at different partners, partners external to health and whether either of you have any comments just to finish off this question session 

Sally Gibson: [00:56:34] Just in New South Wales, because I'm more experienced with that, there are some formal agreements between health and education. I did actually manage the Wellbeing Health Outreach Nurse Program in New South Wales. That started as a small pilot, as I said it actually really came from a drive from the Minister for Mental Health. But it did demonstrate that there are needs that can be met through that partnership. It is a little bit of a contested space. Nurses and schools, it is in some states, not other states. It's quite interesting the differences across jurisdictions. Victoria has got the doctors and schools program and that doesn't exist in most other states. So there are partnerships and I agree that it's really important to try to get that partnership stronger. And I know there is a formal MOU, particularly around mental health between New South Wales education and health as well. So, Dan, did you want to say anything else? 

Dan Waller: [00:57:46] The future with these kinds of partnerships, having those kinds of collaborations is going to be very important. And I think some of these kinds of research studies that are coming out that are showing the benefits of that kind of cross-sector collaboration will be quite helpful in pushing that kind of agenda forward. 

Sally Gibson: [00:58:01] It often does happen in a local area and is not always visible from the centre. So I know a lot of local health districts all through their health promotion programs or their sexual health programs do actually have quite good relationships, often with their local schools doing work in that area. So sometimes and again, that's an example where it's not the youth health policy that might drive those actions but actually the relationships that are really driving some of that work as well. 

Kate Steinbeck: [00:58:29] I think I'm going to have to finish this there, and it's probably a good note to end on the importance of developing relationships. And so I'd like to thank both our presenters for a fantastic presentation, our audience that was very interactive. And we are farewelling the webinar series for 2020. But don't worry, we'll be back in 2021, starting on the 23rd of February. I know it's been a really difficult year for many people, I think a lot of us have experienced loss in many ways, through the Covid pandemic. And I just wish you all health and safety and I hope that you will get to enjoy a holiday break. So thank you, everyone, for attending.