” NACCHO and the Sector Support Organisations appreciate the opportunity to make this submission on behalf of our Member Services.
With circumstances unimproved after many years of multiple policy approaches, there is a dire need to overturn poor mental health outcomes for Aboriginal and Torres Strait Islander people.
This will require attention to the full spectrum of Aboriginal life experience. There needs to be commitment at all levels of government in terms of funding, policy development and support, for the implementation of culturally-appropriate programs and services.
There must be recognition that self-determination of Aboriginal people will be the foundation of true progress.
NACCHO strongly recommends that government engage in meaningful dialogue with it, the Sector Support Organisations and ACCHSs, in relation to the proposals canvassed in this submission, and work in partnership to address the significant and continual inequity of access to culturally-safe mental health and social / emotional wellbeing services for all Aboriginal people.”
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“ In keeping with this Indigenous model of SEWB, AMSANT believes that integrating SEWB,
Mental health and AOD, which work toward preventing and addressing these issues, into
Primary Health Care (PHC) Services is the most cost-effective approach to the delivery of
mental health services throughout rural and remote NT.
In keeping with the model, SEWB programs require funding for multidisciplinary, culturally and trauma informed teams with expertise across these various aspects of wellbeing for Aboriginal communities.
SEWB services are designed to support individuals, families and communities in all aspects of life
that strengthen wellbeing,”
From AMSANT’s seperate submission
The National Aboriginal Community Controlled Health Organisation (NACCHO) welcomes the opportunity to provide input for the Senate inquiry into Accessibility and quality of mental health services in rural and remote Australia.
Aboriginal and Torres Strait Islander people represent approximately 3% of the population, yet are disproportionately over-represented in a negative way on almost every indicia of social, health and wellbeing determinants.[i]
Commonly recognised factors causing these disparities include intergenerational trauma, racism and social exclusion, as well as loss of land and culture.[ii] They are vastly over-represented in mental health services[iii], and evidence of the gap in mental health outcomes compared with their non-Indigenous peers is well documented.[iv]
For example, a 2016 report states that Aboriginal males aged 25–29 years have the highest rates of suicide in the world.[v] Underscoring these health disparities, the rate of admissions to specialised psychiatric care has been found to be double that of non-Indigenous Australians.[vi]
Mental health and wellbeing is integral to the individual and collective ability to think, express and engage productively in work and in life.[vii] A multitude of relevant national frameworks and reforms have highlighted the mental health of Aboriginal and Torres Strait Islander people as a priority, with a focus on prevention and early intervention. The nexus for bridging the gap is cultural security, which includes access to culturally-safe mental health and social / emotional wellbeing services.[viii] However, this access, in particular in regional, remote and very remote locations, is highly inconsistent and in many locations is non-existent.
Aboriginal Community Controlled Health Services
NACCHO is the peak body representing 145 Aboriginal Community Controlled Health Services (ACCHSs) across Australia. ACCHSs provide comprehensive primary health care to Aboriginal and Torres Strait Islander people at over 300 Aboriginal medical clinics. Three million episodes of care are delivered to around 350,000 people each year (over 47% of the Aboriginal population); a third of these in remote areas.
The ACCHS sector is the largest single employer of Aboriginal and Torres Strait Islander people in the country, employing 6,000 staff. Evidence that the ACCHS model of primary health care delivers better outcomes for Aboriginal people is well established. The model has its genesis in the people’s right to self-determination, and is predicated on principles that incorporate a holistic, person-centred, whole-of-life, culturally-safe approach. Without exception, where Aboriginal and Torres Strait Islander communities lead, define, design, control and deliver their own services and programs, they achieve improved outcomes.[ix] The principles of self-determination and community control remain central to the people’s wellbeing and sovereignty.
Aboriginal and Torres Strait Islander people continue to experience disadvantage in equity of access to mental health services. This is a major concern requiring immediate redress by governments at all levels. Despite inequitable levels of funding and resources[x], ACCHSs continue to meet the challenges of addressing the burden of disease and mental ill-health of communities. Further investment is needed to expand and build capacity of the Aboriginal Mental Health Workforce (AMHW), to deliver culturally-safe mental health and social / emotional wellbeing services. As the predominant primary health care providers to Aboriginal people, ACCHSs are best placed to deliver appropriate services. Aboriginal Health Workers and Health Practitioners (AHW/P) as ‘cultural brokers’ are vital to bridge the prevailing gap between mainstream mental health services and Aboriginal consumers’ access to mental health care, treatment and support.[xi]
The nature and underlying causes of rural and remote Australians accessing mental health services at a much lower rate
Aboriginal and Torres Strait Islander people continue to under-utilise health services, despite experiencing poorer health. They are over-represented in rural and remote areas, so the issue of remoteness in accessing mental health services is particularly important for them.[xii] Data from the 2011 Census show that 3% of Australians (669,881) identified as Indigenous; 21% lived in remote or very remote areas[xiii], compared to only 1.7% of non-Indigenous Australians. Aboriginal people represent 16% and 45% of all people living in remote and very remote areas respectively.[xiv]
The geographical challenges in ACCHS availability and lack of resources to access culturally-appropriate mental health services restricts choice for Aboriginal people; this is compounded when they have to travel long distances from their communities for care and treatment. Mainstream services cannot provide culturally-appropriate care for the mental health needs of Aboriginal people, particularly those living in rural, remote and very remote locations.
Culturally-safe mental health services – ACCHS’ preferred provider status
Aboriginal and Torres Strait Islander people identify culture as key to mental wellbeing and evidence shows that culturally-safe early intervention and prevention programs and services are the most effective in reducing poor mental health and suicide.
Like all Australians, Aboriginal people are influenced by their experiences when accessing health services, including cultural responsiveness.[xv] In 2012–13, a reported 7% of Aboriginal adults avoided seeking health care because they had been treated unfairly by doctors, nurses or other staff at hospitals or surgeries.[xvi] Those with mental illness experience extreme social and emotional divorcement, alienation from their families, country of origin and their identity. Self-esteem and a sense of empowerment are important in recovery-based models of care, and arguably the best way to achieve this for Aboriginal people is to hand over control of the design and delivery of services to them.[xvii] In providing culturally-safe, holistic and community-based care, Aboriginal community controlled organisations have been identified as best placed to deliver mental health services.
It is important to emphasise that culture must be considered for best practice mental health models of service for Aboriginal people. This includes the multi-faceted impact of intergenerational trauma and its inextricable link to mental health and social / emotional wellbeing.[xviii]
Despite 30% of Australia’s population living in regional, rural and remote areas[xix], Commonwealth mental health funding is inequitably distributed, and the delivery of services to these locations is severely compromised, resulting in greater costs overall. Ample evidence suggests that better allocation of resources and cost-effective funding in the ACCHS sector would result in better mental health outcomes for Aboriginal people.
Aboriginal and Torres Strait Islander people not seeking the mental health care they need in a timely manner, if at all, due to a lack of culturally-safe services, results in individuals becoming increasingly unwell. This escalates emergency or voluntary admissions to hospitals, usually in an acute state – admission, treatment and follow-up cost around $19,782 per person.[xx] This is a significantly higher cost than investing in ACCHSs to deliver community-based mental health services, closer to where people live, keeping people well in the community and preventing hospital admissions.
Despite the ACCHS sector’s ongoing advice to governments at all levels, about effectively addressing the mental health disadvantage and disparities experienced by Aboriginal Australians, funding continues to be directed to mainstream services. Substantial funding and essential resources are redirected from ACCHSs and administered to Primary Health Networks. This lack of transparency is having a deleterious and inequitable impact on Aboriginal people’ access to appropriate services. Despite the rhetoric, funding needed for ACCHSs is not ending up in Aboriginal hands; if government is serious about closing the gaps in health and mental health services, it is imperative to direct funding for Aboriginal service delivery to the ACCHS sector.
The higher rate of suicide in rural and remote Australia
The 2016 Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project (ATSISPEP) report noted that suicide has emerged in recent decades as a major cause of Aboriginal premature mortality and contributes to overall health and life expectancy gaps. In 2014, suicide was the fifth leading cause of death among Aboriginal people, with the age-standardised rate around twice as high as the non-Indigenous rate.[xxi] Alarmingly, Aboriginal children and young people are particularly vulnerable, comprising 30% of suicide deaths among those under 18 years of age. Suicide is the leading cause of death for Aboriginal people aged 14–34[xxii] and those aged 15–24 are over five times as likely to commit suicide as their non-Indigenous peers.
In Australia, rates of suicide and self-harm are higher in rural and remote areas, [xxiii]; and Aboriginal people are more than twice as likely to commit suicide than non-Indigenous people.[xxiv] From 2001–2010, most suicides among Aboriginal people occurred outside of capital cities, in stark contrast to non‑Indigenous suicides, which mostly occurred within cities.[xxv]
In recent years, several efforts have been made to tailor and implement suicide awareness training for Aboriginal and Torres Strait Islander health workers and communities. However, as highlighted in the ATSISPEP report, efforts to reduce suicide must not only address social and economic disadvantage but narrow the gap in health status. Strategies need to promote healing and build the resilience of ‘individuals, families and communities by strengthening social and emotional wellbeing and culture’.[xxvi]
Addressing the higher rates of suicide in Aboriginal communities is a priority for any plan that aims to reduce suicide in rural and remote areas. It will require investment by all levels of government to increase the response capacity of health workers. Further investment in consultation with the communities is needed to design a national capacity-building strategy to respond to the issue.[xxvii]
The nature of the mental health workforce
A range of strategies and actions are required to create an effective, empowered workforce for the mental health wellbeing of Aboriginal and Torres Strait Islander people. These have been identified in a National Strategic Framework for 2017–2023[xxviii] on this topic. A key requirement is a highly skilled and supported workforce, operating in a clinically and culturally-safe way.
Identifying current capacity and gaps in the workforce is important, to better target investment[xxix]. This includes the organisational capacity of Aboriginal and mainstream mental health services as well as skill and availability gaps in the primary mental health professions – nursing, occupational therapy, psychiatry, psychology and social work. It is also vital to consider the links and development opportunities across the different workforces in mental health, social / emotional wellbeing, alcohol and other drugs, family violence and relevant others.
Aboriginal Mental Health Workforce
Critical to positive mental health outcomes for Aboriginal people in rural and remote areas is a reinvestment in community mental health services, and in a committed workforce. A comprehensive Aboriginal Mental Health Workforce (AMHW) is required to improve the cultural responsiveness and safety of these services, to provide appropriate systems of care.
The AMHW plays an important role as ‘cultural broker’, through its advocacy and cultural advice, in the mental health legislation of a number of jurisdictions. Established in both mainstream health services and the ACCHS, the AMHW delivers specialist, holistic and culturally-safe services, which are key to addressing disadvantage and improving mental health outcomes. It helps to bridge the cultural gap, enabling Aboriginal consumers to effectively access mental health services, including presence of an AHW/P during assessment and treatment.
In recognising that Aboriginal community controlled organisations are best placed to deliver health services to communities, improved coordination between ACCHSs and Local Health Districts is needed. The placement of Aboriginal mental health workers in the ACCHS sector, working in conjunction with mainstream services, could help develop integrated models of care, to increase the capacity and confidence of services to work with communities. This working partnership could potentially progress a historically arduous relationship and would increase the capacity of AHW/P in mental health and access to specialist support.
The uncertain and cyclic funding paradigm is a factor undermining the retention of a skilled Aboriginal workforce, and its training and working conditions. Consequently, this has a deleterious effect on achieving sustained improvements in treatment and care of Aboriginal people with mental health problems, particularly those with complex, severe and persistent illnesses.
The challenges of delivering mental health services in the regions
The challenges for people with mental illness in rural and remote areas are well known, and include distance, availability of health services, lower socioeconomic status, and shortages of GPs, specialist medical services and AHW/P. Most barriers in accessing mental health services in these communities are structural, including cost, transportation, or time constraints.[xxx] Geographic and professional isolation also make rural or remote communities less attractive to mental health practitioners, making it difficult to recruit and retain them.[xxxi]
Lack of funding for the ACCHS sector
A major contributor to the poor delivery of mental health services in rural and remote areas is the lack of funding. In the current context where health services, for mental health in particular, are under extreme pressure to meet urban population needs, the capacity of state governments to fund specialist mental health services to people outside of cities is diminished.[xxxii] The funding transition in 2013, from the Ministry of Health – Office of Aboriginal and Torres Strait Islander Health to the Department of the Prime Minister in Cabinet, led to a reduced AMHW and programs in the ACCHS sector, disadvantaging communities and the sector itself.
Continual under-funding of ACCHSs is a limiting factor that impedes the capacity to improve the mental health outcomes of Aboriginal people, particularly in rural, remote and very remote areas. Government investment is ad hoc, often directed towards mainstream service delivery, with non-Aboriginal services delivering care to Aboriginal people. These services are seen to lack the cultural knowledge, competence, capacity and understanding to effectively engage with Aboriginal people and their communities. Funding referred to mainstream services has resulted in many Aboriginal people failing to present at appointments or dis-engaging due to these services being culturally unsafe or inappropriate. It has also contributed to expensive increases in hospital admission rates for acute and complex conditions.
The ACCHS sector has consistently shown its capacity to achieve better health outcomes for Aboriginal people through delivering comprehensive, culturally-safe health, prevention and early intervention services in a more cost-effective way. However, adequate funding is still required to expand services in regions where they are inaccessible or demand is greater. ACCHSs contend that procurement approaches lacking in cultural safety will not provide equity of access for communities. These approaches, which deny Aboriginal community controlled services the opportunity to access resources to deliver appropriate services related to mental health, will continue to fall short, preventing effective social policy implementation and outcomes for communities and for government.
It is in the government’s interest to invest in the ACCHS sector to provide prevention and early intervention services, due to the significant economic burden of mental illness. There is a strong argument for optimising investment in areas where populations are most at risk and vulnerable.
Service delivery – need for greater coordination
Better services coordination between government and non-government organisations is a significant issue impacting Aboriginal people, particularly to address their needs in a culturally-appropriate and holistic way. Like many governments, the South Australian Government has acknowledged the barriers that departmental silos represent for the provision of appropriate and effective mental health care to Aboriginal people.
The Commonwealth Government’s Better Access to Mental Health Services Initiative is an example. This initiative is intended to mitigate access disparities and provide more coordinated care. However, application of the Modified Monash Model geographical classification system to determine eligibility requirements denies access for Aboriginal people living in many regional, remote and very remote locations, particularly in Western Australia.
Improved coordination of services is essential to reduce hospital admissions and ensure that Aboriginal people do not continue to be ‘lost’ in a system that does not understand or respond to their cultural and mental health needs. Paramount to ensuring consumers receive the right care is a more ‘wrap-around’, culturally-safe, holistic service model, implemented at all levels of government and non-government organisations. The ACCHS sector is the expert in this regard and is best placed to deliver services and educate the mainstream sector, with respect to relevant services for Aboriginal people.
Opportunities that technology presents for improved service delivery
The delivery of mental health services using new technologies is a growing area of practice and research interest. Building capacity within ACCHSs to effectively deliver technology‑based services is a sensible option, but how they will improve patient experience or access must be considered. Online services need to complement rather than replace an early human response in a crisis.
While the relative benefits of online services have not yet been evaluated in terms of their ability to augment traditional face-to-face mental health services, there are positive cost and service efficiencies. Research indicates that web-based services that provide mental health information and support can significantly improve mental health outcomes. New developments mean that cognitive behavioural therapies can be adapted into an online environment and be delivered without a counsellor, while providing the same outcomes at a fraction of the cost.[xxxiii]
Telehealth initiatives – such as teleconferencing and videoconferencing – are being used globally to deliver mental health services (assessment, consultation and therapy), and to fill prevention, assessment, diagnosis, counselling and treatment[xxxiv] service gaps in rural and remote locations. For people living in rural and remote Australia, the recent introduction of a new Medicare rebate, aimed at improving access to telehealth psychological services, is an important step. This means people can claim a rebate for up to seven videoconferencing consultations with psychologists and other mental health professionals. With Medicare data showing that per capita MBS expenditure on mental health services in remote areas is less than a quarter of that in major cities[xxxv], this is indeed a substantial improvement in the supply of services to disadvantaged populations.
A significant benefit of technology is the online access to training and referral advice for health professionals in rural and remote areas. Not only can web-based services have great potential for consumers, they can also offer education to mental health professionals, GPs and other staff.
While many approaches to online service delivery are still in their infancy, there are plenty of opportunities to combine research with new telehealth programs and evaluation of their effectiveness. A number of Member Services are currently trialling telehealth in remote areas with positive results, despite facing challenges with set-up and costs. While there is great potential for the development of mental health internet-based and mobile apps, it is important that these are inclusive and culturally appropriate for Aboriginal consumers. This requires investment and direct involvement of the ACCHS sector.