2010-11 AMA Indigenous Health Report Card - "Best Practice in Primary Health Care for Aboriginal Peoples and Torres Strait Islanders"
- Health and life expectancy
- Access to appropriate primary health care
- Barriers experienced in accessing primary health care
- Best practice in promoting access to primary health care for Aboriginal peoples and Torres Strait Islanders
- Best practice in promoting high quality outcomes in primary health care for Aboriginal peoples and Torres Strait Islanders
- Taking stock of best practice in Australia’s diverse service system
- The challenge for the health system
The gap in health and life expectancy between Aboriginal and Torres Strait Islander Australians and other Australians continues to be significant. There are some indications of change, but these are limited and the changes are gradual. If the gap in health and life expectancy is to be closed by 2030, further sustained efforts are needed to hasten the pace of change.
This will mean tackling the factors that contribute to the poor health of Aboriginal peoples and Torres Strait Islanders, such as low income, limited education, low levels of employment, and poor housing and living conditions. It will also mean an increased focus on the type and quality of health care that is available. The gap in life expectancy will not be closed until Aboriginal peoples and Torres Strait Islanders have the access they need to high quality primary health care. The AMA believes that this lack of access has been partly due to a lack of clarity within successive governments as to what high quality and accessible primary health care for Aboriginal peoples and Torres Strait Islanders should look like.
Australia’s primary health care system is currently undergoing reform. The AMA believes that these reforms should strive for, and be judged by how well they support, best practice in primary health care for Aboriginal peoples and Torres Strait Islanders. The AMA makes recommendations in this Report Card about the characteristics that Australia’s primary health care system needs to ensure this best practice.
In developing its specific recommendations, the AMA has investigated the latest data and evidence about the barriers that stop Aboriginal peoples and Torres Strait Islanders accessing primary health care services. Importantly, the Report Card identifies factors that encourage appropriate access and contribute to high quality health and clinical outcomes - in short, the key characteristics of best practice in primary care for Aboriginal peoples and Torres Strait Islanders.
There are significant service limitations and capacity gaps in primary health care delivery for Aboriginal peoples and Torres Strait Islanders, including in urban and non-remote areas where three-quarters of Aboriginal peoples and Torres Strait Islanders live. Aboriginal peoples and Torres Strait Islanders visit mainstream private general practices and local community health centres, as well as primary care services designed for Aboriginal peoples and Torres Strait Islanders. The challenge for the health reform process is to focus on what can be achieved through collaboration and integration between these services, to ensure continuity of high quality care through coordination, sharing of cultural understanding, resources, expertise, geographical availability, and opportunities to provide care.
Best practice in primary care for Aboriginal peoples and Torres Strait Islanders is about implementing models of collaborative service delivery that sustain continuity of care and are suited to the particular needs of particular regions and locations in Australia.
The AMA believes that best-practice primary health care has to be informed by the perspectives of the Aboriginal peoples and Torres Strait Islanders who are the potential recipients of that health care, and of those who successfully deliver it. This Report Card reflects perspectives from the coal-face in its case studies on models of best practice in different service contexts, including models witnessed by the AMA on site visits to primary care services in remote and urban areas.
Progress to close the gap must escalate significantly. So far, the reforming of Australia’s primary health system has paid scant attention to the health of Aboriginal peoples and Torres Strait Islanders. Planning or implementation has not been conducted in genuine partnership with Aboriginal peoples and Torres Strait Islanders. This perpetuates an unacceptable approach to policy.
Article 23 of the United Nations Declaration on the Rights of Indigenous Peoples states “indigenous peoples have the right to be actively involved in developing and determining health . . programmes affecting them . .” The AMA believes that full and genuine recognition of this right is long overdue in Australia, and that now is the time to change this.
There were an estimated 562, 681 Aboriginal and Torres Strait Islander Australians in 2010, of whom 23.4 per cent lived in remote and very remote locations, while the majority lived in urban areas. An Aboriginal or Torres Strait Islander boy born between 2005 and 2007 can expect to live 11.5 years less than any other Australian boy (67.2 and 78.7 years respectively), and an Aboriginal or Torres Strait Islander girl born in that period could expect to live 9.7 years less than any other Australian girl (72.9 and 82.6 years, respectively) . Fourty per cent of the difference in death and disability is attributable to the poor health of the 23.4 per cent of the Aboriginal and Torres Strait Islanders living in remote and very remote areas.
In 2004-05, Aboriginal peoples and Torres Strait Islanders reported recently visiting a GP or specialist (either in a private practice or an Aboriginal and Torres Strait Islander primary health care service ) at a similar rate to other Australians.
Even when primary care services are available, affordable and culturally accessible, not all Aboriginal peoples and Torres Strait Islanders will be fully aware of when to access those services. This is also a barrier to access.
Best practice in promoting access to primary health care for Aboriginal peoples and Torres Strait Islanders
Services that are reachable and available
Increasing the number and distribution of high quality primary health care services clearly makes more services geographically available. Improving the availability of affordable transport and accommodation near existing services also contributes. In some remote Australian locations, where great physical distances are involved and Aboriginal or Torres Strait Islander communities are small, some health services have developed regionalised models of delivery that involve a larger service in a regional centre supporting smaller services in surrounding communities.
Outreach and community visiting can increase the availability of services, and can promote trust and ongoing relationships with Aboriginal and Torres Strait Islander communities. The outreach role often undertaken by Aboriginal Health Workers is invaluable in these respects, in urban as well as remote contexts. Aboriginal Health Workers are also significant in facilitating the journeys of Aboriginal peoples and Torres Strait Islanders between the range of health services they need.
It is also important to have linkages and coordination between the services and expertise that Aboriginal peoples and Torres Strait Islanders need in their region or locality. Some services have adopted particular approaches to address this. For example, the service model developed by the Queensland Aboriginal and Islander Health Council, integrates Aboriginal and Torres Strait Islander-specific and mainstream services. The need for coordination, integration and continuity of care for Aboriginal peoples and Torres Strait Islanders exists across Australia’s health system, which suggests that a system-wide response is needed.
Services that are culturally acceptable
Aboriginal or Torres Strait Islander cultural values and perspectives can be reflected in health services at different levels. Often, staff can have knowledge about Aboriginal or Torres Strait Islander culture (cultural awareness). But the real difference is made when cultural values and perspectives are incorporated into the organisational arrangements and clinical approaches adopted by primary care services to make them non-discriminatory, more culturally respectful, and ‘culturally secure’ (cultural security).
Actions that contribute to cultural security can include having Aboriginal or Torres Strait Islander doctors, nurses or health care workers on staff, respecting gender-based cultural values and practices in clinical approaches (ie., men’s business and women’s business), having access to interpreter services, and recognising cultural conceptions of health and wellness in clinical practice.
Many services have successfully adopted measures to improve and promote cultural security. The Darebin Community Health Service experienced an 85 per cent increase in its Aboriginal and Torres Strait Islander clients after it employed an Aboriginal access worker, established links with local Aboriginal organizations, and built relationships with local Aboriginal people.
Aboriginal culture is also represented in its strongest form (cultural appropriateness) through Aboriginal communities governing and owning health services. The care provided by Aboriginal community-controlled health services will be culturally appropriate because it is care provided by Aboriginal people for Aboriginal people.
Primary care services will be better accessed in Aboriginal and Torres Strait Islander communities that understand when it is appropriate to seek health care or advice. Health-related community capacity-building, such as that provided by many Aboriginal community-controlled health services and by NGOs such as Save the Children, is valuable in encouraging health-seeking behaviour. Outreach, liaison and ongoing relationships between primary care services and Aboriginal and Torres Strait Islander communities (often through the work of Aboriginal Health Workers) play a great role in this.
Best practice in promoting high quality outcomes in primary health care for Aboriginal peoples and Torres Strait Islanders
Primary health care services also need to produce high quality clinical and health outcomes for Aboriginal peoples and Torres Strait Islanders. The evidence suggests that certain characteristics of services and the health system are very conducive to producing these quality health outcomes.
Culturally secure services
Cultural security is important not only for improved access, but also for the relationships of trust and intimacy that are central to good clinical care, particularly for Aboriginal peoples and Torres Strait Islanders who can be subject to multiple and complex conditions.
Continuity of care and integrated services
Providing comprehensive primary health care and a core set of services is not always possible within a single service setting. Primary health care that is comprehensive and spans a lifetime will call upon a range of services, including allied health services and other social support networks. The capacity of comprehensive primary care to reduce the health gap faced by the Aboriginal and Torres Strait Islander population depends crucially on these necessary services being available, culturally accessible and coordinated. Continuity of care across the service system for Aboriginal peoples and Torres Strait Islanders remains a major challenge for Australia.
Enablers of best practice - appropriate resources, processes and support:
All of these elements of best practice need to be adequately resourced and supported with:
- appropriate infrastructure;
- professional clinical and health expertise;
- sufficient staff, including Aboriginal and Torres Strait Islander staff;
- training support in cultural competence if needed;
- workable funding arrangements for staff stability and adequate remuneration;
- good management capacity and governance, and
- data systems and e-health arrangements.
Of particular importance are established procedures to accurately obtain Aboriginal or Torres Strait Islander identity.
In Australia’s diverse health system, there are different capacities among different types of primary care service and sectors, changing levels of demand for services in different regions of Australia, and variable availability of services. These differences need to be recognised when determining how best practice can be most effectively supported.
Capacities for best practice in Aboriginal and Torres Strait Islander primary care services
Aboriginal community-controlled health services reflect the key elements of best practice very well and, with appropriate resourcing, could reflect best practice to an even greater degree. State, Territory and local community-funded Aboriginal health and medical services that are not Aboriginal community-controlled may also reflect many elements of best practice.
There are currently 152 Aboriginal community controlled primary health care services in Australia, and a limited number of other Aboriginal and Torres Strait Islander primary health care services. Of the 211 Aboriginal and Torres Strait Islander primary health care services receiving Australian Government funding in 2008-09, 130 employed 330 full-time equivalent doctors across Australia (an average of 2.5 doctors per service). A total of 745 full-time equivalent Aboriginal Health Workers were employed in 79 per cent of Aboriginal and Torres Strait Islander services. 87 per cent of these services employed one or more nurses, 58 per cent employed social and emotional wellbeing staff (counsellors, psychologists and social workers), and 15 per cent employed a dentist (not necessarily full-time).
Limited resourcing and support impede the capacity for best practice in Aboriginal and Torres Strait Islander primary health care services. Attracting and maintaining medical staff and maintaining infrastructure and equipment are difficult, particularly in remote locations where the costs of running health services are an estimated 3.5 times higher than in urban locations.
Australia’s primary health care system is currently undergoing reform. It is crucial that the significant improvement of Aboriginal and Torres Strait Islander health should be a central goal in those reforms. This will require the Commonwealth to adequately fund, and appropriately support, the development of best practice primary health care for Aboriginal peoples and Torres Strait Islanders. The following are fundamental preconditions for this:
1. Aboriginal peoples and Torres Strait Islanders must be supported to play a leading role in the planning of their primary health care.
2. Any future arrangement to transfer some or all of primary health care funding to the Commonwealth must ensure that this does not disadvantage Aboriginal community-controlled health services and other Aboriginal medical services at the local level that are currently in receipt of State or Territory funding.
3. Governments must ensure that:
- there is ongoing monitoring to determine what additional services and capacity are required, and where, to close the gap in health inequity;
- access to hospitals and continuity between primary care and acute care for Aboriginal peoples and Torres Strait Islanders is promoted;
- the Lead Clinician Groups being established as part of the COAG health system reform process include medical practitioners involved in the care of Aboriginal peoples and Torres Strait Islanders;
- there is systematic, rather than piecemeal and ad hoc, access to specialist services for Aboriginal peoples and Torres Strait Islanders; and
- the quality and continuity of health care for Aboriginal peoples and Torres Strait Islanders is underpinned by high quality e-health systems within regions.
To close the gap, it is important to support integrated and collaborative models of primary health care for Aboriginal peoples and Torres Strait Islanders, which are suited to particular regional needs and reflect best practice.
4. Priority should be given to funding and supporting Aboriginal community-controlled primary care services, so these services can maximise their high potential for best practice.
A Capacity-building Plan for Aboriginal community-controlled services should be implemented to encompass governance, capital works and recurrent support. This plan should include the following:
- services being funded through a single core of pooled funds for a minimum of five years at a time, and at least three times the per capita MBS utilisation by non-Indigenous Australians (with a rural and remote loading of up to an additional three times);
- implementation of capital works programs to assist Aboriginal communities wishing to develop a new community-controlled health service;
- Aboriginal community-controlled health services being supported for accreditation, including governance, capital works, and service delivery;
- Aboriginal community-controlled health services being supported to provide home visiting services and to have facilities for provision of visiting allied health and specialist services;
- resources for NACCHO affiliates and Torres Strait Islander community-controlled health services to support every Aboriginal and Torres Strait Islander community that wishes to develop its own Aboriginal and Torres Strait Islander primary health service into a legally incorporated community-controlled service;
- where local Aboriginal communities agree, a process of transition to Aboriginal community control should be supported for State and Territory funded Aboriginal health services. This transition should proceed according to frameworks such as the Northern Territory Health Forum ‘Pathways to Community Control’, the Queensland Aboriginal and Islander Health Council Strategic Plan 2010 - 2013, or the Torres Strait Transition to Community Control; and
- development of a workforce for Aboriginal community-controlled health services, including general and specialist medical practitioners through to practice managers and support staff.
Private general practices and community health centres have a crucial role to play in order to close the gap. Some of them will potentially have a significant number of Aboriginal people and Torres Strait Islanders among their patient population. Others will have few, if any. Investment in best practice primary care for Aboriginal peoples and Torres Strait Islanders in these services should reflect these differences.
5. Private general practices and community health centres providing significant services to Aboriginal people should be linked where possible with Aboriginal community-controlled services. The resulting set of services should be resourced and supported to develop best practice primary care for Aboriginal people and Torres Strait Islanders to an extent that is appropriate to the size of its potential Aboriginal and Torres Strait Islander patient population.
The AMA recognises the significant funding that COAG has committed to the Commonwealth’s Indigenous Chronic Diseases package, and its measures and incentives to support general practices in providing high quality and accessible care for Aboriginal peoples and Torres Strait Islanders.
6. The following are among a range of further measures that could be supported in private general practices or community health centres to empower them to better provide accessible and high quality primary care for Aboriginal peoples and Torres Strait Islanders:
- support for services to meet accreditation standards that require Aboriginal and Torres Strait Islander identity to be routinely recorded in active patient records;
- incentives to allow routine bulk-billing of patients identified as Aboriginal or Torres Strait Islander;
- further incentives to utilise Aboriginal and Torres Strait Islander-specific MBS items and GP mediated health interventions such as immunisation;
- in practices with a potential Aboriginal and Torres Strait Islander patient population, the completion of a cultural safety training program that has met the RACGP and/or ACRRM educational standards. It is important that the training is provided through practical and flexible learning options;
- the development and implementation of Aboriginal and Torres Strait Islander-endorsed curricula for Registrars training towards Fellowship of the RACGP and ACRRM that ensures core competencies in matters relating to the health of Aboriginal peoples and Torres Strait Islanders; and
- measures and incentives to train and employ more Aboriginal health workers in practices in locations that have a significant Aboriginal and Torres Strait Islander population.
The AMA believes that Aboriginal Health Workers play a very significant role in providing and facilitating access to primary care services.
7. The role of Aboriginal Health Workers should be strengthened and supported through:
- implementation of the negotiated national award for pay;
- development of stronger career pathways between schooling and the training sector;
- a commitment that at least some of the training for Aboriginal Health Workers takes place at the local community level to encourage local recruitment and sustained workforce;
- ensuring that Aboriginal Health Workers have the necessary support to prevent them being disadvantaged and discouraged by the obligations and responsibilities imposed on them from July 2012 as registered practitioners under the Health Practitioner Regulation National Law Act 2009;
- amendments to the Medicare Benefits Schedule Aboriginal Health Worker rebates to ensure there is parity in eligibility to claim across all States and Territories;
- the introduction of an incentives scheme for Aboriginal Health Workers (particularly in remote areas); and
- development of a training pathway for progression to graduate primary healthcare staff level.
Greater efforts should be made to train a health and medical workforce and increase the research and knowledge base for Aboriginal and Torres Strait Islander health.
8. A national network of Teaching Health Centres of Excellence in Aboriginal and Torres Strait Islander health should be established across Australia to act as training and research hubs for health and medical professionals seeking high quality practical experience in Aboriginal and Torres Strait Islander health in primary and tertiary care settings. These Centres should be linked into existing undergraduate and graduate training processes, and also include a focus on cultural safety training.
The AMA believes that best practice in primary health care for Aboriginal and Torres Strait Islander peoples must be informed by the perspectives of the people who receive that health care, and the perspectives of those who successfully deliver the care. The AMA conducted site visits to primary care services in remote and urban locations to gain these perspectives. The following examples reflect some of the key characteristics of best practice in primary health care delivery to Aboriginal and Torres Strait Islander peoples in different service contexts.
The Queensland Aboriginal and Islander Health Council and the Institute for Urban Indigenous Health
(a model of collaboration for an expanding urban Aboriginal and Torres Strait Islander population)
The Queensland Aboriginal and Islander Health Council (QAIHC) is the peak body representing Aboriginal community-controlled health services in Queensland. QAIHC facilitates the provision of comprehensive primary care as well as specialist care, community programs, and programs in environmental health. In response to the rapidly expanding urban Aboriginal and Torres Strait Islander population in South East Queensland and the drastic under-servicing of that population, QAIHC undertook strategic planning to regionalise the delivery of primary care services for local Aboriginal and Torres Strait Islander people and integrate that service delivery with mainstream providers and private general practices.
As part of its response to the under-servicing of local Aboriginal and Torres Strait Islander communities, QAIHC has supported four community-controlled health services in South East Queensland to form the Institute for Urban Indigenous Health (IUIH). The IUIH integrates health planning and servicing for Aboriginal and Torres Strait Islander communities in this region, and strengthens service relationships between local Aboriginal and Torres Strait Islander health services, Divisions of General Practice, private practitioners, allied health providers and hospitals. The IUIH has developed and implements an eight-step service model for chronic disease. It starts with a comprehensive health assessment that captures a patient’s total health status, rather than starting with a single disease diagnosis, which can often miss other relevant health conditions and risk factors.
The Majellan Medical Centre, Queensland
(a model of relationship building and small practical changes in private general practice)
The Majellan Medical Centre (MMC) is a practitioner-owned private billing group practice in the Moreton Bay area. The area has an Aboriginal and Torres Strait Islander population but no Aboriginal and Torres Strait Islander -specific primary health care services. Local Elders approached Queensland Health about the poor availability of services for the local Aboriginal and Torres Strait Islander community, and MMC was in turn contacted. In negotiations between MMC and the Moreton Bay Regional Elders Council, a number of practical strategies were developed to improve Aboriginal and Torres Strait Islander peoples’ access. These were bulk billing of all Aboriginal and Torres Strait Islander patients (by doctors who agreed); one session time each week specifically for Aboriginal and Torres Strait Islander patients (the Indigenous “clinic”), and a volunteer bus service to the clinic. The MMC patient registration form was modified to appropriately capture Aboriginal and Torres Strait Islander status, and MMC staff were fully briefed on the clinic. Queensland Health and others partnered in this initiative, and the district Aboriginal and Torres Strait Islander health worker attended clinic sessions to facilitate patient referrals and recalls, and to ensure cultural safety for patients. MMC holds monthly meetings with the Elders and other stakeholders to maintain community ownership. In the first 12 months operation of the MMC clinic, there was a dramatic increase in registered Aboriginal and Torres Strait Islander clientele, from 10 to 147, and average monthly consultations increased from five to 40.
Katherine West Health Board
(a hub and spoke model of remote health service delivery)
The Katherine West Health Board (KWHB) is an Aboriginal community-controlled health organization that provides clinical, emergency and preventative services to people within a 162, 000 sq/km region in the north western part of the Northern Territory. KWHB is governed by an 18 member Board of Aboriginal representatives from the communities in the region. These Board members provide advice about the health concerns and priorities faced by their communities. As well as having a health centre in the larger regional centre of Katherine, KWHB owns and operates health centres in seven communities in the region, which are staffed by GPs, nurses, qualified and trainee Aboriginal Health Workers, administrative staff, and visiting specialists. KWHB has a mobile health team that travels to remote outstations and cattle properties in the region. A key aim of the KWHB is to develop strategic alliances and friendships between Aboriginal and mainstream or Government entities and agencies responsible for health-related services in the region.
KWHB provides comprehensive primary care to its clients through a range of programs including, among others, child health, healthier young families, sexual health, social and emotional wellbeing, chronic conditions, environmental health and hygiene, and nutrition and physical activity. KWHB reinforces strong collaboration and communication between its regional health centres, and between the health programs and streams in KWHB. The AMSNet satellite shared IT network system facilitates this communication across the region. Storage of, and ready access to, patient records across the regional health centres, including mobile access, is provided through the Communicare IT platform. Advice on the cultural appropriateness of materials and programs used by KWHB in the region is provided by the Ngumpin Reference Group of Board members and past and current Aboriginal Health Workers from local communities in the region. KWHB produces health outcomes in the region that are better than average on nearly all of the key health performance indicators used in the Northern Territory.
Inala Indigenous Health Service
(a model of mainstream success in Aboriginal and Torres Strait Islander health)
The Inala Community Health Centre is a Queensland Government-funded mainstream health service established in 1977. In 1995, in response to a very low representation of local Aboriginal and Torres Strait Islander people among patients (approximately 12), the Inala Indigenous Health Service was established within the broader Health Centre. Local Indigenous people were consulted and strategies were implemented to increase the degree to which local Indigenous people accessed the Indigenous Health Service. Initial strategies included employing more Aboriginal and Torres Strait Islander staff, having a more culturally appropriate waiting room, providing cultural awareness training to staff, stronger communication with the Aboriginal and Torres Strait Islander community, promoting intersectoral collaboration and liaison with Aboriginal community-controlled services in the area, and attending interagency network meetings.
Between 1995 and 2000, 899 new Indigenous patients had attended Inala Indigenous Health Service. In 2006 the Service was allowed to Medicare bulk-bill. This enabled additional health and medical staff to be employed, and the full potential of the MBS Aboriginal and Torres Strait Islander health check items and chronic disease items was utilized. By 2008, the Inala Indigenous Health Service was able to provide specialist services, and employed Aboriginal and Torres Strait Islander health and community workers who provide outreach immunizations, child playgroups, and nutrition and chronic disease self-management programs. The Service had also taken on a significant teaching and research role in Aboriginal and Torres Strait Islander health. By 2008, the Service had 22 full-time staff members, and had access to allied health services, drug and alcohol services, mental health services, and child and health services. There are currently 5,000 Aboriginal and Torres Strait Islander patients registered with the Service who complete 1,500 doctor consultations per month - a very substantial increase on patient numbers and consultations since the Service began 13 years earlier. In 2010, the Service received a substantial grant from the Queensland Government to expand to become the South East Queensland Centre of Excellence in Indigenous Primary Care. The Centre of Excellence will be completed in June 2012.
The Centre for Aboriginal Primary Health Care Training, Education and Research (CAPTER) at the Kimberley Aboriginal Medical Services Council
(a model of regional support in teaching and research in Aboriginal primary care)
The Kimberley Aboriginal Medical Services Council (KAMSC) is a regional collective of five independently incorporated Aboriginal community-controlled health services in the remote Kimberley area of northern Western Australia. The Centre for Aboriginal Primary Health Care Training, Education and Research (CAPTER) provides a range of education and training programs, including, Aboriginal Health Worker training, education and training for GP Registrars which involves clinical practice in Kimberley towns and remote communities, involvement in population health programs and local health promotion, and health research; and long- and short-term medical undergraduate placements. CAPTER is expanding its research profile, and has conducted a range of projects on Aboriginal primary health care, including the social and emotional wellbeing of Aboriginal youth. CAPTER promotes increased levels of GP services in the region, good working relationships between doctors and Aboriginal Health Workers, and encourages sustained interest among doctors in working in Aboriginal health. CAPTER is the only program of its kind based in an Aboriginal community-controlled health organisation in Australia.
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*The references are contained in the attached PDF.