Building better systems of care for Aboriginal and Torres Strait Islander people:findings from the kanyini health systems assessment

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“Consistent with our theoretical understandings of kanyini, staff frequently commented on the obligations they felt to reach people and act in their best interests.

This need to hold and nurture people was most profoundly felt by Aboriginal Health Workers (AHWs).”

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Background

Australian federal and jurisdictional governments are implementing ambitious policy initiatives intended to improve health care access and outcomes for Aboriginal and Torres Strait Islander people. In this qualitative study we explored Aboriginal Medical Service (AMS) staff views on factors needed to improve chronic care systems and assessed their relevance to the new policy environment.

Methods

Two theories informed the study: (1) „candidacy‟, which explores “the ways in which people‟s eligibility for care is jointly negotiated between individuals and health services”; and (2) kanyini or holding‟, a Central Australian philosophy which describes the principle andobligations of nurturing and protecting others. A structured health systems assessment, locally adapted from Chronic Care Model domains, was administered via group interviews with 37 health staff in six AMSs and one government Indigenous-led health service. Data were thematically analysed.

Results

Staff emphasised AMS health care was different to private general practices. Consistent with kanyini, community governance and leadership, community representation among staff, andcommitment to community development were important organisational features to retain and nurture both staff and patients. This was undermined, however, by constant fear of government funding for AMSs being withheld.

Staff resourcing, information systems and high-level leadership were perceived to be key drivers of health care quality. On-site specialist services, managed by AMS staff, were considered an enabling strategy to increase specialist access. Candidacy theory suggests the above factors influence whether a service is„tractable‟ and „navigable‟ to its users. Staff also described entrenched patient discriminationin hospitals and the need to expend considerable effort to reinstate care.

Conclusions

Some new policy initiatives (workforce capacity strengthening, improving chronic care delivery systems and increasing specialist access) have potential to address barriers highlighted in this study. Few of these initiatives, however, capitalise on the unique mechanisms by which AMSs „hold‟ their users and enhance their candidacy to health care.

Kanyini and candidacy are promising and complementary theories for conceptualising health care access and provide a potential framework for improving systems of care.

Theme 1: AMSs are different from private general practice

At all sites staff emphasised the unique aspects of AMS service delivery when compared with private general practice. In particular, engagement with local Aboriginal and Torres Strait Islander communities was repeatedly affirmed as the main difference. Staff viewed the typeof care they provided to be comprehensive, responsive to community expectations and patient rather than business oriented. By contrast, private general practice was viewed as focussing on maximising business revenue and providing reactive rather than preventive health care. It was also felt to inadequately acknowledge the particular needs of Aboriginal and Torres Strait Islander people.

I suppose, as an Indigenous doctor, you often get (patients saying) “I‟m happy to talk to you about this, but I wouldn‟t really want to talk to the GP down the road about it…..If it’s something to do with emotional, cultural, spiritual stuff, then that really does need to be addressed. But, you know, mainstream practices might not see it as „true‟ medicine. (GP1, regional AMS2)

Although community linkages are known to be an important component to chronic care, the depth of community connection in AMSs goes beyond this. Even for the only noncommunity governed health service, staff stressed the importance of ensuring community input and that this is usually not appreciated in mainstream services.

Even though we’re a mainstream health service we do work really strongly with the community. There‟s nothing more important than having local people (on staff)…that liaise between the community and us…We still have that strong contact, especially with the elders… Normally mainstream health services never venture out in Indigenous health to actually work with thecommunity and not many (patients) come to them. (Clinical director, urban AMS1)

Consistent with our theoretical understandings of kanyini, staff frequently commented on the obligations they felt to reach people and act in their best interests. This need to hold and nurture people was most profoundly felt by Aboriginal Health Workers (AHWs). One AHW stated that her work „doesn‟t just stop when we finish work‟. These obligations constitute a powerful mechanism for enhancing the candidacy of Aboriginal and Torres Strait Islander communities to health care. For AHWs there was an unconditional quality to the care provided, subtly blending the more demarcated work responsibilities with diffuse personal obligations in the community. Whilst these obligations may manifest quite differently for non-Indigenous staff a similar dedication beyond the ordinary was apparent. This duty to reach people also helps explain why health promotion constitutes a key part of service activity. Bridging clinical services with activities that develop community capacity wereviewed as central to health service function.

Daniel (pseudonym), an Aboriginal project officer, works on a shared responsibility agreement with the football club.…I think that is a really good example of delivering health in a very different way and engaging thecommunity‟s strengths. Rugby league is a huge factor for a man and it shows in figures that men attending the clinic are still under represented….So this work has seen an investment of infrastructure in the community sector as well as furthering this clinic. (AHW project officer 1, urban AMS1

In order for an AMS t o „hold‟ and nurture its community, this engagement is needed at all levels of the organisation, not just with the governing board. The employment of local Aboriginal and Torres Strait Islander staff across a variety of positions allows this holding to be adequately enacted. It affirms community linkages and the consequent legitimacy of the organisation.

Being a community controlled service you not only have it (community control) at the board level but it should be reflected in the organisational structure right through to even the groundsmen…it gives the staff themselves a sense of belonging and knowing that it is owned by the community. We all live in this community so we’re a part of the organisation and we‟re working for it, showing to the wider community that we are able to work at all these different levels..(AHW1, regional AMS3)

A key component to enhancing candidacy to health care is that services are easily navigated by their users. Staff from all professional backgrounds particularly commented on the availability of transport services as a key component to a navigable health service. Rather than merely an ancillary support, transport was viewed as an integral part of health care itself.

Staff commented that health care standards were heavily influenced by the availability of transport and that its absence „ defeats the purpose of us being here‟. For the two remote services, transport was critically important. One service provided daily visits to homelands and transport to the major referral centre for acute or specialist care. This consumedsubstantial monetary and human resources. For the other remote site airplane transportservices were especially dire with long wait times and patients having to travel alone toattend appointments. This left many fe eling vulnerable when „stuck‟ without family in the referral centre. For some people this impacted greatly on future decisions to seek specialistcare.

Thus transport is a key mechanism by which people are supported to navigate the system

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