NACCHO Aboriginal Health : The Role of Doctors in Closing the Gap AIDA Policy Statement 2016

AIDA

“AIDA maintains that Aboriginal Community Controlled health services (ACCHSs) are best placed to deliver this care, and should be adequately resourced with well-trained staff to do so.

Additionally, constraints on funding and staffing mean that while around 140 ACCHSs provide placements situated within a primary health care model for medical students and trainee doctors, filling such placements is a significant logistical challenge. “

This is compounded by the lack of recognition of Aboriginal and Torres Strait Islander health as an identifiable specialty, which has broader adverse impacts on health service delivery.

From the AIDA Policy Statement 2016 Download for all references

FINAL-The-Role-of-Doctors-in-Closing-the-Gap

The Australian Indigenous Doctors’ Association (AIDA) recognises the importance of well-trained and culturally safe doctors in providing appropriate health care, and in turn, working towards closing the gap in the unacceptable health disparities between Aboriginal and Torres Strait Islander people and non-Indigenous Australians.

In 2016 – the 10 year anniversary of the commencement of the Close the Gap Campaign for Indigenous Health Equality; it is timely to reflect on the contribution doctors have made, and continue to make to this campaign and some of the ongoing challenges to meeting the targets.

Fostering the growth of the Aboriginal and Torres Strait Islander medical workforce is imperative in improving Indigenous health outcomes. This can be achieved through both increasing the number of Aboriginal and Torres Strait Islander doctors, as well as ensuring the provision of culturally safe health services.

Close the Gap in 2016: An overview of progress and challenges

Although there has been a significant reduction in adult and child Indigenous mortality rates over the period 1998-2014, the target to close the gap in overall Indigenous life expectancy by 2031 is not on track1. As of 2010-12, the life expectancy for Indigenous men was 69.1 years (a gap of 10.6 years from that of non-Indigenous men), and 73.7 years for Indigenous women (a gap of 9.5 years from that of non-Indigenous women).

While the gap in avoidable deaths has narrowed 27% from 1998 to 2012; over the period 2008-2012, Aboriginal and Torres Strait Islander people still died at three times the rate of non-Indigenous people from avoidable diseases.

These gaps indicate that much more needs to be done to ensure that culturally and clinically appropriate care is given to Aboriginal and Torres Strait Islander people at all stages of life and AIDA recognises the critical role doctors can play in redressing this broader systemic need.

AIDA supports long-term and sustainable measures that focus on improved health outcomes, noting that it takes time for investments in health and changes in policy to produce statistically measurable improvements.

For example; the uptake of health assessments by Aboriginal and Torres Strait Islander people over the period July 2009 to June 2014 has nearly tripled, which demonstrates the positive impact that needs-based health policy can have.

Why aren’t we there yet?

There is still a long way to go to fulfil the Close the Gap targets. AIDA notes that ongoing challenges and barriers to improved health outcomes for Aboriginal and Torres Strait Islander people are also impacting on opportunities to really close the gap.

Systemic barriers and the health workforce

Accessible, consistent and culturally safe primary and specialist health care needs to be available to Aboriginal and Torres Strait Islander communities across rural, regional and urban areas of Australia. AIDA is aware of the ongoing challenges around recruitment and retention of staff for health services across the country with challenges impacting on urban, rural and remote areas.

This includes particular challenges around attracting the right candidates to take up placements outside urban areas. Short-term workforce solutions in primary and specialist health care delivery for Indigenous populations are just that; closing the gap requires a well-planned and adequately resourced health workforce that both responds to the professional development and training needs of health workers, but is also well-equipped to deal with the complex and generally higher needs of Aboriginal and Torres Strait Islander communities.

AIDA recognises that the entire spectrum of the health workforce from primary care through to hospital and specialist medical care has a responsibility to not only understand the critical health needs of Aboriginal and Torres Strait Islander people, but also have the skills and training to provide appropriate, meaningful and effective care to address the health needs of our communities.

Part of providing effective and culturally safe treatment involves practitioners forming long-term relationships with the communities which they serve.

AIDA maintains that Aboriginal Community Controlled health services (ACCHSs) are best placed to deliver this care, and should be adequately resourced with well-trained staff to do so. Additionally, constraints on funding and staffing mean that while around 140 ACCHSs provide placements situated within a primary health care model for medical students and trainee doctors, filling such placements is a significant logistical challenge. This is compounded by the lack of recognition of Aboriginal and Torres Strait Islander health as an identifiable specialty, which has broader adverse impacts on health service delivery.

Chronic disease management

Chronic disease accounts for around three quarters of the gap in mortality rates between Aboriginal and Torres Strait Islander and non-Indigenous Australians. Responding to chronic diseases requires committed investment in the promotion and support of healthy lifestyle behaviours by health care service providers9. Although both mainstream health centres and ACCHSs have a role to play in addressing chronic disease, the latter have proved to offer equal if not better care regarding prevention and management.

Aboriginal health services are better positioned to provide the support and information required by Indigenous patients for the management of chronic disease within their specific cultural context, as a part of holistic and culturally appropriate health care. However, the Closing the Gap Campaign Steering Committee has noted inadequate government spending on ACCHSs, which is not reflective of greater health needs.

This means that ACCHSs remain underfunded, despite the crucial role they have to play in closing the gap in Indigenous health outcomes related to chronic disease.

Mental health and suicide

AIDA notes with great concern that between 2008 and 2012, suicide was the leading cause of death due to external causes for Aboriginal and Torres Strait Islander people, reflecting a lack of targeted interventions to promote mental health wellbeing for Indigenous people. AIDA reinforces the recommendation made in the 2012 and 2013 National Report Cards on Mental Health and Suicide Prevention that mental health be included as a distinct target in the Closing the Gap campaign.

This additional measure provides much-needed recognition of the profound effects of intergenerational trauma on Aboriginal and Torres Strait Islander people, such as that experienced by the Stolen Generations and the flow-on effects to health outcomes today.

General Practitioners are often the first point of contact for people experiencing mental health issues and play a critical role in early intervention and ongoing management. As such – primary health services, hospitals and other service delivery agencies, must be well staffed and resourced to provide optimal mental health care to Aboriginal and Torres Strait Islander people. AIDA advocates for increased resourcing across all areas of the health system that respond to mental health needs, to deliver culturally appropriate services and programs for Aboriginal and Torres Strait Islander communities.

Government policy and funding

AIDA maintains that the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013-2023 (Implementation Plan) is the road map to closing the gap on the unacceptable health disparities between Aboriginal and Torres Strait Islander and non-Indigenous Australians.

As the Implementation Plan was developed through the National Health Leadership Forum and with bipartisan support, AIDA calls for adequate resourcing through appropriate budget measures and targeted policy development and implementation as required.

AIDA hopes to see Commonwealth funding for medical Specialist Training Programs (STP) at minimum, maintained at current levels with a view to increasing over time based on evidence concerning greatest areas of need. This is an important aspect to broader closing the gap objectives, as STP funding enables junior doctors be seconded to areas where they can both provide services and receive relevant training and skills development in the broader context of Aboriginal and Torres Strait Islander health needs.

Further, AIDA is also supportive of the call from the Close the Gap Campaign Steering Committee for a new approach to government health funding based on equity, where a mechanism for allocation is developed to ensure an equitable share of mainstream funding that is both proportionate and reflective of Indigenous health needs.

The Case for Parity: Increasing the number of Aboriginal and Torres Strait Islander doctors

Indigenous clinicians can only serve a small number of Indigenous patients on one day, but can potentially influence a whole generation of students.

AIDA’s goal is to reach population parity of Aboriginal and Torres Strait Islander doctors, and to ensure that Indigenous medical students, junior doctors, and trainees are successful in their education and training.

The current level of representation of the Aboriginal and Torres Strait Islander population within the cohort of Australian doctors is well below population parity, which is roughly 3%18. According to the Department of Health, in 2014, 261 out of the 85,510 employed medical practitioners in Australia- or 0.31%19- identified as Aboriginal and/or Torres Strait Islander. Reaching population parity would require the addition of approximately 2,300 more Aboriginal and Torres Strait Islander doctors to this cohort.

In 2015, the Medical Deans Australia and New Zealand reported a total of 265 currently enrolled Aboriginal and Torres Strait Islander medical students at all year levels. AIDA’s aim is to support and grow this group of future doctors, with the dual goal of parity and cultural safety.

Although we are working hard to reach these targets – parity in number of Indigenous doctors should not be the final objective. AIDA envisions a health workforce that is adequately trained and resourced to meaningfully respond to the diverse, complex and often higher health needs of the Aboriginal and Torres Strait Islander population.

Working towards a culturally safe health system that is free of racism

The National Aboriginal and Torres Strait Islander Health Plan 2013-2023 (Health Plan) states that both cultural factors and racism are determinants in the health of Aboriginal and Torres Strait Islander people21. The Health Plan includes acknowledgement that the incidence of racism in the delivery of health services to Aboriginal and Torres Strait Islander people contributes to low rates of access to health services, echoing the sentiment of AIDA’s 2013 position paper on cultural safety .

In a recent study on the health impacts of discrimination, it was found that racial discrimination negatively impacts upon Indigenous peoples’ health care seeking behaviour; on how Indigenous clients gain and pass on knowledge about their health; and on Indigenous mental health3. Accordingly, AIDA affirms Strategy 1B in the Implementation Plan, which specifically refers to eliminating racism against Aboriginal and Torres Strait Islander people within the health system.

Heath care service providers must be cognisant of the need for patient-centred holistic care for Aboriginal and Torres Strait Islander patients.

The Australian Government’s 2014 report on the Aboriginal and Torres Strait Islander Health Performance Framework (Health Performance Framework) identifies that Aboriginal and Torres Strait Islander health indicators must go beyond quantifying levels of morbidity and mortality, and incorporate physical, mental, social, and spiritual components of health.

In practical terms, this means that when providing care to Aboriginal and Torres Strait Islander patients, doctors should be trained to ask questions in an appropriate manner, be mindful of complexities in patient histories, know how to access additional support if required, and develop culturally appropriate treatments and follow-up plans.

A key indicator of the current poor levels of cultural safety in health care delivery within the hospital setting is the unacceptable rate of discharge against medical advice for Aboriginal and Torres Strait Islander patients. In the two years to June 2013, as reported in the Health Performance Framework, the rate of discharge against medical advice for Indigenous patients was eight times that of non-Indigenous patients.

This equates to around 5% of all Indigenous hospitalisations in the period July 2011 to June 2013 resulting in discharge against medical advice, as compared to the non-Indigenous rate of 0.5%27. This rate illustrates that hospital services are not meeting the needs of Aboriginal and Torres Strait Islander patients to the same extent as the needs of non-Indigenous patients. The Health Performance Framework states:

Indigenous status was the single most significant variable contributing to whether a patient would discharge themselves from hospital against medical advice.

From this data – it is clearly evident that cultural safety training for doctors and hospital staff, and the importance of recognising patients’ cultural needs, will directly contribute towards closing the gap in Indigenous health outcomes.

AIDA supporting doctors in closing the gap

Growing the Aboriginal and Torres Strait Islander doctor workforce, and shaping a culturally safe health care system more broadly, is a dynamic and long-term process. All stages of the medical education and training continuum have a part to play, and this is recognised in the AIDA 2020 Strategic Plan.

AIDA has an important role in influencing better training and curriculum outcomes for Aboriginal and Torres Strait Islander doctors and the entire medical workforce.

AIDA is working to support Indigenous medical students by promoting pathways into and through medicine, through our university engagement, the AIDA Student Representative Committee and other member support activities.

We are also working with junior doctors and advocating across the broader workforce by providing medical college-accredited workshops, which foster continual professional development and networking.

Our high level collaboration with the Committee of Presidents of Medical Colleges, and individual medical colleges ensure that AIDA has a role in shaping and influencing key policy areas where they matter most to our members and broader education and training matters focusing on Aboriginal and Torres Strait Islander health. Additionally,

AIDA runs an annual member event, along with cultural and collegiate workshops, to promote the engagement of our Indigenous medical student and doctor membership.

AIDA commends the supportive relationships formed between all tiers of its membership, noting the important role of senior Aboriginal and Torres Strait Islander doctors as a source of inspiration to younger medical students and junior doctors.

The professional and cultural support fostered within our group of members is underscored by their persistence, resilience, and drive to contribute towards shaping a more inclusive and representative health system for Aboriginal and Torres Strait Islander medical practitioners and patients alike.

Through our ongoing work and engagement across the education, training and workforce sectors, AIDA envisages an increase in the number of Aboriginal and Torres Strait Islander doctors and the growth of a more culturally safe health care system.

We know these two goals are critical in meeting the Close the Gap targets and achieving equitable and sustained health and life outcomes for Aboriginal and Torres Strait Islander people. In the next 10 years, AIDA would like to see sustainable and ongoing policy commitment, financial investment and leadership from Government that supports the entire health sector respond to, and redress the unacceptable health disparities identified in the Close the Gap Campaign.

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