NACCHO Alert : Download #NSQHSStandards Users Guide Aboriginal Health : National Safety and Quality Health Service Standards

 

 ” At the request of the National Aboriginal and Torres Strait Islander Health Standing Committee, the Commission undertook a project to improve the care provided to Aboriginal and Torres Strait Islander people in health service organisations, using the framework of the National Safety and Quality Health Service (NSQHS) Standards.”

Download National-Safety-and-Quality-Health-Service-Standards-User-Guide-for-Aboriginal-and-Torres-Strait-Islander-Health

See More Downloadable Resources below

Why have Aboriginal and Torres Strait Islander–specific actions?

The two compelling reasons to have specific actions that meet the needs of Aboriginal and Torres Strait Islander people are:

  1. The historical and contemporary context of Aboriginal and Torres Strait Islander health
  2. The unique and diverse cultures of Aboriginal and Torres Strait Islander people.

1.Historical and contemporary context of Aboriginal and Torres Strait Islander health Aboriginal and Torres Strait Islander people are among the most socially and economically disadvantaged groups in Australia.2

The current poor health and wellbeing of many Aboriginal and Torres Strait Islander people stems largely from the effects of colonial policies and their ongoing legacy. These policies have resulted in loss of land, family and community connections, and denial of free cultural expression and growth across generations. They affect the physical, emotional, social and spiritual dimensions of wellbeing for Aboriginal and Torres Strait Islander individuals and communities.

The continuing impacts on health and wellbeing are evident in the unacceptable gaps between Aboriginal and Torres Strait Islander people and other Australians in health outcomes, including infant and child mortality, disease burden, and life expectancy. Significant barriers to accessing effective and safe health care contribute to these gaps. Therefore, it is important that people experience safe and high-quality health care based on need.

Meaningful, lasting relationships with the Aboriginal and Torres Strait Islander community are integral to redressing past wrongs and moving towards an equitable healthcare system for all Australians.

The project considered the safety and quality issues typically affecting care provided to Aboriginal and Torres Strait Islander people in health services, and investigated how the NSQHS Standards could be used to leverage improvements in the safety and quality of care provided to Aboriginal and Torres Strait Islander people in mainstream health services.

We represent the oldest continuous culture in the world; we are also diverse and have managed to persevere despite the odds because of our adaptability, our survival skills and because we represent an evolving cultural spectrum inclusive of traditional and contemporary practices. At our best, we bring our traditional principles and practices – respect, generosity, collective benefit, collective ownership – to our daily expression of our identity and culture in a contemporary context. When we are empowered to do this, and where systems facilitate this reclamation, protection and promotion, we are healthy, well and successful, and our communities thrive. (Dr Ngaire Brown, New York, 20123)

Closing the Gap4 in Aboriginal and Torres Strait Islander disadvantage is a national priority that the Australian Government and all state and territory governments are committed to addressing. It is the responsibility of all health service organisations to consider and action their part in closing the gap in health disparities experienced by Aboriginal and Torres Strait Islander people.

2.Unique and diverse cultures of Aboriginal and Torres Strait Islander people

Aboriginal and Torres Strait Islander people have world views that differ from other Australians. Although language varies across the country, four core concepts are found consistently among Aboriginal and Torres Strait Islander communities. In the Arrernte (A), Warlpiri (W), Pitjantjatjara (P) and Luritja (L) language groups of South Australia and the Northern Territory, these concepts are:

  • Altyerre (A), Jukurrpa (W), Tjukurpa (P) or Tjukurrpa (L). The religious interpretations of the profound bonding of people to one another, to their country and to the species of animals and plants inhabiting it. It is continually renewed by its expression in song, dance, verbal narratives of creation stories and re-enacted continually in ceremonial journeys.

• Walytja (L, P) or Warlalja (W). The system of extended kinship; the organisational scaffolding for social roles and authority; the pathways of distribution and communication.

• Ngura (L, P) or Ngurra (W). Country to which people belong; which they may use; always subject to the obligations of looking after it and care …; including its celebration.

• Kanyini (L, P) or Mardarni (W). Which is to have, to hold [and] to care. Kanyini is a verb which reflects a commitment, a full engagement; vitalising again and again all that went before and all that will go after.5

Aboriginal and Torres Strait Islander people have a holistic view of health that is not adequately met by the biomedical model of health care. For Aboriginal and Torres Strait Islander people, health is:

… not just the physical wellbeing of an individual but refers to the social, emotional and cultural wellbeing of the whole Community in which each individual is able to achieve their full potential as a human being, thereby bringing about the total wellbeing of their Community. It is a whole-of-life view and includes the cyclical concept of life–death–life.6

While there are similarities, there is also much diversity. There were more than 250 Aboriginal and Torres Strait Islander language groups across Australia, and it is estimated that 120 languages are still spoken today.5

It is important to note that each language group has its own unique values and belief systems. Therefore, if a health service organisation is to provide effective care to its local Aboriginal and Torres Strait Islander people, or the communities that regularly access care, it will need to understand the diverse cultures and values of the people in the organisation’s catchment and of the patients using its services.

The approach and results :

  • Consultation with a wide range stakeholders including individuals, leaders in Aboriginal and Torres Strait Islander health, policy makers, Aboriginal and Torres Strait Islander health organisations, managers, clinicians and members of the Aboriginal and Torres Strait Islander health workforce
  • Mapping the safety and quality issues for Aboriginal and Torres Strait Islander people to the NSQHS Standards
  • A literature review of relevant evidence based strategies to improve the safety and quality of care for Aboriginal and Torres Strait Islander people.

Based on the findings of this project:

  • Six Aboriginal and Torres Strait Islander specific actions have been included in draft version 2 of the NSQHS Standards
  • A series of guides to drive best practice care for Aboriginal and Torres Strait Islander people has been developed based on the NSQHS Standards.

The next stage of this project is now underway which builds on previous work and again aims to improve the safety and quality of health care provided to Aboriginal and Torres Strait Islander people in mainstream health service organisations using version 2 of NSQHS Standards.

The objectives of this project are to:

  • Raise awareness of the issues facing Aboriginal and Torres Strait Islander patients in mainstream health service organisations
  • Improve the safety and quality of care for Aboriginal and Torres Strait Islander patients by supporting mainstream organisations to implement the NSQHS Standards, using resources that contain effective, evidence-based strategies to address Aboriginal and Torres Strait Islander health issues
  • Improve the Aboriginal and Torres Strait Islander cultural awareness skills of the surveyor workforce whose members assess health service organisations to the NSQHS Standards.

Resources

The guides contain editable text boxes for those health service organisations who wish to include local content. Please contact the Commission’s Advice Centre on 1800 304 056 to discuss any additional changes

National Safety and Quality Health Service Standards User Guide for Aboriginal and Torres Strait Islander Health (PDF 2MB)

Overview: Guide to better care for Aboriginal and Torres Strait Islander Consumers (Word 503KB)

1. Setting safety and quality goals for Aboriginal and Torres Strait Islander people in health service organisations (Word 576KB)

2. Cultural competence in caring for Aboriginal and Torres Strait Islander consumers (Word 421KB)

3. Improving identification rates of Aboriginal and Torres Strait Islander consumers (Word 397KB)

4. Creating safe and welcoming environments for Aboriginal and Torres Strait Islander consumers (Word 408KB)

5. Effective and safe communication with Aboriginal and Torres Strait Islander consumers (Word 417KB)

6. Comprehensive care for Aboriginal and Torres Strait Islander consumers (Word 419KB)

NACCHO Aboriginal Health @SNAICC @NationalFVPLS respond to the Royal Commission Into Child Sex Abuse : 14.3% of survivors were Aboriginal and Torres Strait Islanders

“Strong cultural identity, connections to family and community, and cultural care practices are non-negotiable factors in keeping our children safe.

It is imperative that, especially following such a thorough process, all of the recommendations from this report are accepted and implemented,” said Ms Williams.

The pain and injustices of the past have been acknowledged, and must now be redressed. At the same time, we must tackle current challenges to ensure our children are kept safe in family and culture.”

Sharron Williams, SNAICC Chairperson. 14.3% of survivors were Aboriginal and Torres Strait Islander people. Those that shared their stories with the Royal Commission spoke not only of sexual physical and emotional abuse, but also of racism and cultural abuse. See Part 2 below

 ” The National Family Violence Prevention and Legal Services Forum (National FVPLS Forum) welcomes the landmark findings of the Royal Commission into Institutional Responses to Child Sexual Abuse.

The report identified the need for specific initiatives to be developed for Aboriginal and Torres Strait Islander people who experience child sexual abuse, as well as to prevent the removal of Aboriginal and Torres Strait Islander children from their families and communities.”

Antoinette Braybrook, Convenor of the National FVPLS Forum.See Part 3

” We must focus our efforts on the future, but we must also ensure we properly deal with the past. Perhaps the single most important aspect of this is the redress scheme.

What happens now with redress?

The national redress scheme is behind schedule and must be finalised with sufficient funding, and government and institutional commitment.

What happens now with redress? See Part 4 Below

Part 1 Here’s What The Royal Commission Into Child Sex Abuse Said About Survivors

From Buzzfeed

Thousands of stories, and statistical insights, about Australians who suffered as children at the hands of sexual abusers have come to light in the 1000-plus page, 17-volume final report of Australia’s Royal Commission into Institutional Responses to Childhood Sexual Abuse, handed down on Friday.

The report paid tribute to the bravery of survivors for speaking out, in more than 8,000 private hearings, about what had been done to them, and the destruction and chaos it had wrought upon their lives.

“Many spoke of having their innocence stolen, their childhood lost, their education and prospective career taken from them and their personal relationships damaged,” the report said. “For many, sexual abuse is a trauma they can never escape. It can affect every aspect of their lives.”

The commissioners wrote that without the personal stories of survivors they could not have done their work.

“These stories have allowed us to understand what has happened,” the report said. “They have helped us to identify what should be done to make institutions safer for children in the future.

“The survivors are remarkable people with a common concern to do what they can to ensure that other children are not abused. They deserve our nation’s thanks.”

The report published statistics based on the experiences, where information was available, of 6,875 survivors who testified at the commission up to May 31, 2017.

It found that the majority of survivors (64.3%) were male.

More than half said they were aged from 10 to 14 when they were first sexually abused.

Female survivors tended to be younger when they were first sexually abused than male survivors.

14.3% of survivors were Aboriginal and Torres Strait Islander people.

4.3% of survivors said they had a disability at the time of the abuse.

3.1% of survivors were from culturally or linguistically diverse backgrounds.

93.8% of survivors said they were abused by a man.

83.8% of survivors said they were abused by an adult.

10.4% of survivors were in prison at the time they gave evidence to the royal commission.

The average duration of child sexual abuse in institutions was 2.2 years.

36.3% of survivors said they were abused by multiple perpetrators.

These stories were told in private sessions, with one or two commissioners present to give survivors as safe as possible an environment to share their distressing and traumatic stories.

Almost 4,000 of those stories have been published with the final report in the form of short, de-identified narratives.

One published narrative was about “Keenan”, an Aboriginal man who was abused as a child and has spent most of his adult life in prison.

He is one of the 10.4% of survivors who spoke to the commission from prison, where he was serving a lengthy sentence for attacking a man he thought was a paedophile.

“I’ve got a deadset hatred of sex offenders,” he told the commission. “An absolute hatred.”

Keenan told the commission that he was fostered by a “nice white family” in the mid-1980s when he was five, who he loved and who became his adoptive parents. But he felt different in the white neighbourhood as an Aboriginal child: “I was a bit worried about what people would think when my family is white and I was black.”

He started going to the local Catholic church when he was nine to learn about Holy Communion. It was here that the parish priest took an interest in him.

“He asked my parents if he could do private studies with me at the church and my parents thought, you know, the sun shined out of his arse, they thought he was the top bloke,” he said.

The priest abused Keenan when they were alone together, touching Keenan’s thigh and penis. Keenan said he didn’t want to do it, but the priest “roared” at him that no matter what he told his parents, they wouldn’t believe him.

After two more instances of abuse, Keenan tried to tell his father about what was happening, but was dismissed. “No, you’re probably looking at it the wrong way. He’s probably just mucking around with you”.

Keenan refused to go back to see the priest, and changed churches. The abuse shattered him — he lost faith in God, and felt betrayed by his father.

“The two main things I believed in the strongest weren’t there for me,” he said.

After that, Keenan decided to suppress the abuse, saying: “I’ll find a little part of my body I can fold it up into and I don’t have to talk about it anymore.”

But as with so many survivors, it dramatically changed the course of Keenan’s life. He said he became “a prick of a kid” and at 15 moved out of home with a girlfriend and lost touch with his adoptive family for years. In the ensuing years, he wound up in juvenile detention and later adult prison.

Keenan told his girlfriend about the abuse, and she was supportive. In his mid-20s, he told his mother, and she was upset he hadn’t told he earlier. His relationship with his father remained difficult.

Other than those conversations, sharing his story with the commission was the first time Keenan had spoken about the abuse in 30 years.

“Even now in court they asked if I’ve been touched as a kid I said ‘No’. ‘Cause it’s got nothing to do with them. It’s taken me a long time to talk about this. Opening up again today about it, it makes me feel like I’m a kid again. It’s bringing back a lot in my mind I’ve learnt how to put away,” he said.

“At the age I am now I’ve got to get rid of that burden that’s sitting inside me, I think that’s the thing that keeps bringing me back to jail. ‘Cause jail’s a good place to hide.”

The support services page for the Royal Commission is here.

If you or someone you know needs help contact your nearest ACCHO or , you can call 1800 Respect (1800 737 732) or visit www.1800respect.org.au, or contact Lifeline on 13 11 14 or visit www.lifeline.org.au.

Part 2 ROYAL COMMISSION REPORT RECOGNISES CULTURE AS A PROTECTIVE FACTOR FOR CHILDREN AND CALLS FOR HEALING FOR ABORIGINAL AND TORRES STRAIT ISLANDER SURVIVORS OF CHILD SEXUAL ABUSE

 SNAICC welcomes the release of the final report of the Royal Commission into Institutional Responses to Child Sexual Abuse. We take this opportunity to acknowledge those who bravely shared their stories with the Royal Commission, and the barriers to disclosure that prevent many other survivors from coming forward.

The Royal Commission’s final report confirms the lived pain of past and present effects of child removal. The Royal Commission heard from many survivors who had been forcibly removed from their families as children and then sexually abused in institutions that should have kept them safe.

Aboriginal and Torres Strait Islander survivors who shared their stories with the Royal Commission spoke not only of sexual physical and emotional abuse, but also of racism and cultural abuse.

It is clear that child sexual abuse in institutions is not only a thing of the past; it is still a problem today.

As Aboriginal and Torres Strait Islander children are significantly overrepresented in out-of-home care systems today, addressing vulnerabilities and implementing the Royal Commission’s recommendations must be guaranteed as a matter of urgency.

The Royal Commission recognised the alarming over-representation of Aboriginal and Torres Strait Islander children in out-of-home and called for reform of the contemporary system ensure children are safe from abuse in the future. It recognised that culture is an important protective factor for Aboriginal and Torres Strait Islander children.

The Royal Commission’s final report recognises the importance of the full and proper implementation of the Aboriginal and Torres Strait Islander Child Placement Principle, and recommends partnership with Aboriginal and Torres Strait Islander organisations and community representatives to ensure this is met.

The Royal Commission also makes important recommendations to fund Aboriginal and Torres Strait Islander healing approaches and improve support for kinship carers, including ensuring that financial support and training are equivalent to that provided to foster carers.

“It is imperative that, especially following such a thorough process, all of the recommendations from this report are accepted and implemented,” said Ms Williams.

“The pain and injustices of the past have been acknowledged, and must now be redressed. At the same time, we must tackle current challenges to ensure our children are kept safe in family and culture.”

The publication of the final report concludes an extensive and exhaustive process, spanning several years, thousands of private sessions with survivors, and close examination of traumatic personal experiences by six Commissioners, including Professor Helen Milroy, who has brought specific expertise and understanding to issues relating to Aboriginal and Torres Strait Islander children.

SNAICC thanks the all those involved in the Royal Commission for their dedicated and sensitive approach to the examination of this national tragedy – one that has been unresolved for far too long.

Part 3 Greater investment into supporting Aboriginal and Torres Strait Islander communities’ essential to preventing institutional child sexual abuse, says landmark Royal Commission report

The National Family Violence Prevention and Legal Services Forum (National FVPLS Forum) welcomes the landmark findings of the Royal Commission into Institutional Responses to Child Sexual Abuse. The report identified the need for specific initiatives to be developed for Aboriginal and Torres Strait Islander people who experience child sexual abuse, as well as to prevent the removal of Aboriginal and Torres Strait Islander children from their families and communities.

“The Royal Commission has acknowledged the importance of culture and developing specific initiatives to keep our children safe,” said Antoinette Braybrook, Convenor of the National FVPLS Forum.

“We work with Aboriginal and Torres Strait Islander women and children nationally who have experienced family violence, the Royal Commission identified that many of those have been victims of child sexual abuse.”

The National FVPLS Forum played a pivotal role in raising awareness of the Royal Commission and supporting Aboriginal and Torres Strait Islander people to share their stories, receiving Federal Government funding to work in partnership with Knowmore Legal Services.

“It’s the trust and confidence that our people have in us that takes us into those communities to raise awareness and provide support. We engage and work with many Aboriginal and Torres Strait Islander people nationally who experience ongoing trauma resulting from child sexual abuse” said Ms Braybrook. “Our people’s access to Aboriginal community controlled organisations, like FVPLSs, is essential”.

“Aboriginal community controlled organisations, like FVPLSs, are best placed to provide this support” said Ms Braybrook “Our services are holistic and culturally safe.”

“Many Aboriginal and Torres Strait Islander people have shared their stories, now we need greater investment in Aboriginal community controlled organisations to provide the support that our people need.”

Part 4 The royal commission’s final report has landed – now to make sure there is an adequate redress scheme

From The Conversation

The Royal Commission into Institutional Responses to Child Sexual Abuse has performed its task magnificently. Its scale, complexity and quality is unprecedented. Its work is already being acknowledged internationally as a model of best practice.

As a nation, we can be proud of the commissioners and their staff. We should acclaim the courage of all survivors, including those who informed the commissioners about their experiences, and we should honour those who have not lived to see this day.

We must recognise the integrity and strength of those who advocated for the inquiry, including survivors, their families, journalists and police. We should applaud former prime minister Julia Gillard for initiating the commission, and the current federal government for ensuring it was adequately resourced.

But this is not the end. The real work begins now. Australian governments and major social institutions now have not only the opportunity, but the responsibility, to create lasting social change. Their responses will be monitored here, including through requirements to report on their actions, and around the world.

The royal commission’s impact

This watershed inquiry has created the conditions for a seachange in how society deals with child sexual abuse in institutions, which can flow to our treatment of sexual abuse in other settings.

Our society’s leaders can build progress from the pain of former failings. Not meeting this responsibility would surely stick as a lifelong regret for those in positions to cement change. Fulfilling this imperative can leave a legacy of which these government and institutional leaders can be proud.

Substantial progress has already been made. The commission’s earlier reports have influenced important changes to civil justice systems, criminal justice systems, organisational governance, and prevention, including situational prevention in child and youth-serving organisations.

The Child Safe Standards now promoted by the commission are substantially embedded in legislation in several states, requiring organisations to adopt comprehensive measures to prevent, identify and respond appropriately to child sexual abuse.

Civil laws have been amended in most jurisdictions to allow claims for compensation, holding individuals and organisations accountable.

In some states, new requirements to report known and suspected cases apply through special “failure to report” and “failure to protect” offences in criminal laws. They also apply through separate reportable conduct schemes that add essential independent external oversight.


Read more: Royal commission recommends sweeping reforms for Catholic Church to end child abuse


Yet much remains to be done. The reforms already made in some states must be adopted elsewhere to create national consistency.

Accountability of individuals and organisations is essential to create cultural change, and needs to be achieved through both civil systems (such as following Western Australia’s recent bill enabling lawsuits against organisations that previously could not be sued, such as the Catholic Church), and criminal systems (for example, prosecuting those who harbour offenders, and removing criminal law principles that compromise criminal prosecutions).

Other state and territory mandatory reporting laws need to be harmonised, as recommended by the commission. Many of the commission’s new 189 recommendations are rightly directed towards prevention, especially through the Child Safe Standards, including their requirements for education, codes of conduct, situational prevention, and the commitment required of organisations’ leadership.

 

The bill for the scheme remains before parliament, awaiting a committee report due in March 2018. It is yet to receive the commitment of all states, territories, and relevant organisations.

The commission recommended the scheme be operational by July 1, 2017, with an upper cap of A$200,000 and an average redress payment of $65,000. Under the bill, the scheme’s cap is $150,000, substantially below the recommendation, and even further below the average payment awarded in Ireland of more than €60,000 (about A$92,200). In Ireland, the highest payment was more than €300,000 (about A$461,000).

The Australian scheme contains three elements. First, a monetary payment as tangible recognition of the wrong suffered by a survivor. Second, access to counselling and psychological services (estimated at an average of $5,500 per person). Third, if requested, a direct personal response from the responsible institution(s), such as an apology.

Not all survivors will apply to the scheme, as many are not financially motivated. However, it is an essential part of a healing response. This has been shown internationally in Canada, Ireland and elsewhere.

Redress schemes are more flexible and speedy, with less formality and cost, and less trauma and confrontation, than conventional legal proceedings. Payments are not intended to replicate the amount that would be payable under a formal civil compensation claim, and instead are far lower.

Accordingly, institutions should recognise the lower financial commitment required to discharge their ethical obligation to participate compared with their liability in formal civil compensation amounts, especially since recent reforms to civil statutes of limitation have removed time limits and allow a claim to be commenced at any time.

Ten key aspects of the proposed Australian scheme are:

  1. People are eligible to apply to the scheme if they experienced sexual abuse in an institution while they were a child, before July 1, 2018.
  2. A lower evidentiary threshold applies, meaning that eligibility for a redress payment is assessed on whether there was “a reasonable likelihood” the person suffered institutional sexual abuse as a child.
  3. Applicants who have received redress under another scheme or compensation through a settlement or court judgment are still eligible, but prior payments by the institution will be deducted from the amount of redress.
  4. Only one application per person can be made; where a person was abused in more than one institution, provisions enable the decision-maker to determine the appropriate share of each institution.
  5. Applicants can access legal assistance to help determine whether to accept the offer of redress.
  6. A person who accepts an offer of redress must sign a deed of release, meaning the institution(s) responsible for the abuse will not be subject to other civil liability.
  7. Payments are not subject to income tax.
  8. Reviews of decisions are limited to internal review, and not to merits review or judicial review.
  9. Criminal liability of offenders is not affected.
  10. The scheme is intended to open on July 1, 2018, and operate for ten years; applications need to be made at least 12 months before the closing date of June 30, 2028.

Read more: When it comes to redress for child sexual abuse, all victims should be equal


Five further factors need to be accommodated by the scheme to ensure it functions properly and complies with the clear recommendations of the royal commission.

  1. The upper cap should be $200,000 to ensure sufficient recognition of severe cases.
  2. To ensure equal access to the scheme, legal assistance must be made available to assist people in making applications.
  3. Governments and institutions should opt in as soon as possible and commit resources to discharge their duty to participate in the scheme.
  4. Governments – federal or state – should be the funder of last resort in all cases where the institution is unable to reimburse the Commonwealth (for example, where the institution no longer exists, or lacks resources to participate).
  5. The method of determining the amount of the payment, based on the severity of the abuse, its impact, and other relevant factors, must be made available as soon as possible so it can be adequately debated.

The commission’s work contributes a historic, international legacy. The sexual abuse of children in institutions will be revealed in more nations in coming years. This will involve some of the same religious institutions in which it has been found here to be so prevalent, and so heinously concealed and facilitated. Simply due to population, countless children will be shown to be affected.

For this reason, our governments and institutions must now ensure their actions add to the royal commission’s example, and demonstrate to other countries how civilised societies should respond.

Aboriginal Health #COAG #ClosetheGap :’Historic’: Sweeping overhaul of #Indigenous #ClosingtheGap strategy welcomed

  ” Congress is the key facilitator for generational change. Now is the time for all levels of government to invest, to meet the needs of our people to develop the capacity to participate economically, socially and culturally.

All indications are that this could well mark the start of new era of Aboriginal and Torres Strait Islander Affairs.” 

Congress Co-Chair Rod Little

” Ministerial representatives from federal, state and territory governments recommitted to uniting efforts for Indigenous affairs across Australia, with a focus on the Closing the Gap Refresh and continuing to improve engagement between Aboriginal and Torres Strait Islander peoples and governments.

Council members agreed the importance of moving to a strength-based approach to Closing the Gap that celebrates Indigenous achievement, as well as addressing persistent disadvantage.”

COAG Council on Indigenous Affairs see full communique Part 2 Below

Photo Above : PM at Closing the Gap Annual report 2017

Background  Feb 2017 Closing the gap: Australia is failing on Indigenous disadvantage goals

Closing the Gap set for overhaul after failing to improve outcomes for Indigenous Australians

After almost a decade of failure to significantly improve outcomes for Indigenous Australians, the Federal Government is working on a major overhaul of the Closing the Gap strategy.

ABC reports

Key points:

  • Government will invest $300b into Closing the Gap strategy over next 10 years
  • Indigenous leaders say government must seek advice of Aboriginal and Torres Strait Islander people
  • Final Closing the Gap strategy won’t be implemented until middle of 2018

It has been almost 10 years since commonwealth and state Governments committed to targets to close the gap in Indigenous health, education and employment, but there has been limited progress in key areas.

Prime Minister Malcolm Turnbull signalled a new approach was needed when he tabled the ninth annual Closing the Gap report to Parliament earlier this year, that showed some targets were stagnating and others were going backwards.

Documents obtained by the ABC show the Federal Government is now seeking feedback on a drastically different approach, that will broaden the agenda to include more cultural and community targets.

The new framework, which would guide $300 billion of investment over 10 years, would also consider if objectives like home ownership, community safety and overcoming trauma should become priorities.

It is expected the final strategy will not be implemented until the middle of 2018, almost 18 months after Mr Turnbull indicated change was needed.

Federal Indigenous Affairs Minister Nigel Scullion me with his state and territory counterparts to discuss proposed changes, with months of consultation with the Indigenous community expected to follow

Fairfax Media reports

Fairfax Media understands some ministers present pushed back against the timeframe proposed by the federal government, which would see a new strategy finalised by June next year.

“You can’t put forward a new framework without including and consulting Aboriginal people. And with the current time frame the federal government is putting forward, it doesn’t look like there’s going to be enough time,” Victorian Aboriginal Affairs Minister Natalie Hutchins told Fairfax Media.

“If we were going to just ram it through or rush it through, I don’t think we’d get the results. It’s better that we get it right.”

Ahead of the meeting, Senator Scullion said there was “an opportunity to redouble our efforts in the areas where we need to do better and develop a truly national, collaborative approach to improving the lives of First Australians”.

Any changes to Closing the Gap will affect the approximately $30 billion that is spent on Indigenous people annually by federal and state governments, according to the Productivity Commission.

Congress Press Release Historic Meeting Points to Positive Working Relations

Relationships between National Congress of Australia’s First Peoples and State, Territory and Federal Governments took a positive turn today. For the first time in 8 years Indigenous Affairs was the focus of a COAG Ministerial Council meeting in Canberra.

This meeting was initiated by Minister for Indigenous Affairs Nigel Scullion and welcomed by National Congress and all who attended.

Congress Co-chairs Jackie Huggins and Rod Little heard directly from all State and Territory Ministers and Ministerial representatives in relation to their priorities for Indigenous affairs and where National Congress can play a vital role in delivering improvements for Indigenous people in their respective jurisdictions.

Reflecting on the significance and substance of this historic meeting, Co-Chair Jackie Huggins stated, “Congress hopes that this is the beginning of a concerted and cooperative effort towards alleviating the drastic social conditions that face Aboriginal and Torres Strait Islander people.”

Stepping out of the meeting after a 45 minute presentation to all attendees, Co-Chair Rod Little stressed that, “Congress is the key facilitator for generational change. Now is the time for all levels of government to invest, to meet the needs of our people to develop the capacity to participate economically, socially and culturally. All indications are that this could well mark the start of new era of Aboriginal and Torres Strait Islander Affairs.”

National Congress is ready and willing to deepen the relationships with all levels of government. By working in close partnership with all States and Territories, National Congress aims to realise their respective Indigenous Affairs goals under a single agreement framework.

23 October 2017, Canberra

Part 2 COAG Communiqué

Today’s first meeting of the new COAG Ministerial Council on Indigenous Affairs brought together ministers from all Australian governments in Canberra to re-energise national efforts on Indigenous policy. The Council was welcomed to Ngunnawal and Ngambri country by Tina Brown of the Ngunnawal peoples.

Ministerial representatives from federal, state and territory governments recommitted to uniting efforts for Indigenous affairs across Australia, with a focus on the Closing the Gap Refresh and continuing to improve engagement between Aboriginal and Torres Strait Islander peoples and governments.

Co-Chairs of the National Congress of Australia’s First Peoples

The Council welcomed the Co-Chairs of the National Congress of Australia’s First Peoples, Ms Jackie Huggins and Mr Rod Little, who spoke about the need for Commonwealth, State and Territory governments to work in partnership with Aboriginal and Torres Strait Islander peoples and how governments can better engage with Indigenous advisory and representative bodies.

Council Priorities

Council members discussed priorities for Indigenous affairs, noting the importance of the process to refresh Closing the gap. Members discussed the importance of listening to, and working with Aboriginal and Torres Strait Islander peoples, and noted there are multiple models for achieving this around the Federation, including through work underway in some jurisdictions toward local decision making and treaties.

Closing the Gap Refresh

Council members agreed the importance of moving to a strength-based approach to Closing the Gap that celebrates Indigenous achievement, as well as addressing persistent disadvantage. The Council recommitted to working in partnership with Aboriginal and Torres Strait Islander peoples on the issues that affect them, creating economic and social opportunities, noting that community support and a shared sense of ownership are essential for delivering meaningful, practical change.

All jurisdictions highlighted their commitment to working with Aboriginal and Torres Strait Islander people to refresh the agenda for the next ten years of Indigenous Affairs in Australia.

Council Attendees:

  • Senator the Hon Nigel Scullion, the Minister for Indigenous Affairs (Commonwealth) (Chair)
  • The Honourable Sarah Mitchell, Minister for Aboriginal Affairs (New South Wales)
  • The Honourable Natalie Hutchins, Minister for Aboriginal Affairs (Victoria)
  • The Honourable Mark Furner, Minister of Aboriginal and Torres Strait Islander Partnerships and Local Government (Queensland)
  • Mr Reece Whitby, Parliamentary Secretary (Western Australia)
  • The Honourable Kyam Maher, Minister for Aboriginal Affairs (South Australia)
  • Ms Sarah Courtney, Parliamentary Secretary to the Premier (Tasmania)
  • Ms Rachel Stephen-Smith, Minister for Aboriginal and Torres Strait Islander Affairs (Australian Capital Territory)
  • The Honourable Ken Vowles, Minister for Primary Industry and Resources (Northern Territory)

Honoured Guests

  • Ms Jackie Huggins, Co-Chair of the National Congress of Australia’s First Peoples
  • Mr Rod Little, Co-Chair of the National Congress of Australia’s First Peoples

NACCHO congratulates the Australian Indigenous Doctors Association #AIDAconf2017 @AIDAAustralia for 2O years of strong leadership

 ” Since the first Indigenous doctor graduated in 1983, more than 300 other Aboriginal and Torres Strait Islander people have gone onto become doctors.

The Australian Indigenous Doctors Association (AIDA) has played an important role in contributing to the growth of this critical workforce through the strong support it provides Indigenous doctors and medical students,

This week AIDA will celebrate its 20th anniversary during its annual conference starting today .

A recent commitment to work with the Australian Government, National Aboriginal Community-Controlled Health Organisation (NACCHO) and the Council of Presidents of Medical Colleges (CPMC) will see further improvements in health systems capabilities to deliver appropriate services for Aboriginal and Torres Strait Islander peoples “

Karen Wyld is covering the #AIDAconf2017 conference for the Croakey Conference News Service 

Picture above : AIDA emerged from a conference of Aboriginal and/or Torres Strait Islander medical students and doctors in 1997

You can read some of the stories of its members in this publication

Download PDF Journeys into Medicine

AIDA Journeys-

Watch recent interview with Dr Mark Wenitong on NACCHO TV

Watch recent interview with Dr Ngiare Brown  on NACCHO TV

Karen Wyld is covering the conference for the Croakey Conference News Service and provides a comprehensive preview below. Karen Wyld is an author, consultant and freelance writer from South Australia. Of Aboriginal descent (Martu), she has a background in community development, social/health research, health workforce training, and Aboriginal community-controlled health. ( See  full info below )

Family Unity Success – 20 years strong,

This week, there will be more than a few doctors in the house at Cypress Lakes Resort in Pokolbin, New South Wales, when the Australian Indigenous Doctors Association (AIDA) holds its annual conference.

This year’s AIDA conference theme is Family Unity Success – 20 years strong, which is well reflected in the program. Featuring VIP guest speakers, informative sessions with inspiring leaders in health, and numerous cultural activities and networking opportunities, the program runs from Wednesday 20 through to Saturday 23 September 2017.

From little things, big things grow

AIDA is a strong, supportive network of over 500 doctors, medical students, and partner organisations. This year’s conference will be its biggest ever, with more than 360 registered delegates and speakers.

AIDA emerged from a conference of Aboriginal and/or Torres Strait Islander medical students and doctors in 1997. That inaugural event was held at Salamander Bay in the Hunter region of NSW. And in 2017 AIDA returns to NSW, this time Hunter Valley, for their 20th year celebration.

Since its inception, AIDA has been achieving its goals of contributing to equitable health and life outcomes and the cultural wellbeing of Indigenous people by reaching population parity of Indigenous medical graduates and supporting a culturally safe health care system.

The culturally-appropriate high-level support that AIDA provides members, especially Aboriginal and/or Torres Strait Islander medical students, is both a contributing factor to the association’s success and to an expanding Indigenous health workforce.

With a Secretariat led by CEO Craig Dukes, AIDA continues to grow from its base in Old Parliament House Canberra. The Board of Aboriginal and/or Torres Strait Islander doctors and a student Director provide direction to the Secretariat.

AIDA’s Student Representative Committee (SRC) is another means of supporting Aboriginal and/or Torres Strait Islander medical students. With representatives from most Australian medical universities, the SRC provides advice to AIDA on initiatives to support Indigenous medical students to succeed in their studies and personal career aspirations.

Through strengthening collaboration with key medical bodies and colleges, AIDA continues to influence the Australian health care system to work towards strategic changes within provision of health services for Aboriginal and/or Torres Strait Islander peoples.

Conference highlights

Starting on Wednesday 20 September, with member-only sessions and the AGM, this year’s AIDA conference has plenty to offer delegates. In the morning, James Wilson Miller and Laurie Perry of the Wonnarua Nation will conduct the welcome to Country. Dr Kali Hayward, AIDA President, and Dr Louis Peachey, AIDA Life Member, will present a session on the history of AIDA, and the vision for its future.

The agenda will be complemented with cultural activities, including a dance workshop and yarning circles. The day will finish with an evening gathering that includes a smoking ceremony, dance performances, unveiling of art, and Indigenous astronomy.

With renowned journalist and filmmaker Dr Jeff McMullen as MC, Thursday and Friday’s agenda has many informative sessions and skills-based workshops. AIDA has also attracted many Australian and international special guest speakers, including:

  • The Hon Ken Wyatt AM, MP, Minister for Indigenous Health
  • Senator Richard Di Natale, Leader of the Australian Greens
  • Professor Tom Calma, AO National Coordinator Tackling Indigenous Smoking, and Consultant to Commonwealth Health
  • Associate Papaarangi Reid, Deputy Dean Maori, Tumuaki, University of Auckland
  • Dr Michael Gannon, President of the Australian Medical Association
  • Mr Philip Truskett AM, Chair-Elect of the Council of Presidents of Medical Colleges, and AIDA Patron
  • Dr Martina Kamaka, Associate Professor, Department of Native Hawaiian Health, John A. Burns School of Medicine
  • Dr Nathan Joseph, Chairperson, Te Ora

A presentation by the Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women’s Council Ngangakaris on Thursday is another highlight in an agenda that features Aboriginal and Torres Strait Islander perspectives of health and wellbeing, and cultural activities.

Thursday evening, AIDA’s SRC will be hosting a networking event with sponsorship from National Aboriginal and Torres Strait Islander Health Workers Association (NATSIHWA). And on Friday night the Platinum Gala Dinner and awards ceremony will be held, MCed by Steven Oliver, Aboriginal writer, performer and comedian.

On the Saturday, an optional tour of Baiame Cave is offered to delegate and guests, or a choice of three specialised professional development workshops.

Moving forward with cultural safety

After presenting a VIP address in the plenary session on the Friday, the Hon Ken Wyatt MP will be participating in the Cultural Safety Panel. With his previous experience working within the health sector, and current appointment of Minister for Aged Care and Indigenous Health, Minister Wyatt’s contribution to this panel will be a conference highlight.

The cultural safety panel builds on recent work that AIDA has conducted in strengthening cultural competency within the Australian health sector. In 2016, AIDA conducted a survey to collate feedback from members on incidents of bullying, racism and lateral violence in the workplace. AIDA is now working on strategies to address the key issues that arose from the survey report.

A recent commitment to work with the Australian Government, National Aboriginal Community-Controlled Health Organisation (NACCHO) and the Council of Presidents of Medical Colleges (CPMC) will see further improvements in health systems capabilities to deliver appropriate services for Aboriginal and Torres Strait Islander peoples

Presidential perspectives

Dr Kali Hayward, AIDA President, is looking forward to celebrating the 20th year milestone with fellow AIDA members, by reliving AIDA’s history and acknowledging those who have contributed to its success.

Since the first Indigenous medical graduate in 1983, there are now over 300 Aboriginal and/or Torres Strait Islander doctors, specialists and surgeons. AIDA’s strong support of the Indigenous medical workforce and mentoring of Indigenous students in medicine has contributed to this outstanding growth in the number of medical practitioners.

Hayward acknowledges the supporting environment that AIDA’s conferences provide Indigenous medical students, and speaks highly of the Growing Our Fellows session. This provides Aboriginal and/or Torres Strait Islander medical students an opportunity to have a one to one conversation with a representative from fifteen medical colleges. With strong competition to get into college training programs, this is unique opportunity for students to discuss their career pathways through medicine.

Whilst the CEO and Secretariat have worked tirelessly to ensure this year’s conference will be special, AIDA’s strong reputation has meant that they received many offers of support. This has resulted in an enviable conference program. Dr Hayward says that AIDA is very appreciative of people giving their time, with many VIP speakers and guests eager to celebrate the 20th milestone.

Hayward also stated that she “…is very proud to be the current President. Proud of the students, and other AIDA members. And proud to be able to help create a safe environment for students and doctors to come together.”

Looking at how far AIDA has come since 1997, there is much to be proud of, and many examples of Family Unity Success to celebrate at the conference.

Join the conversation

Karen Wyld is covering the #AIDAconf2017 for the Croakey Conference News Service

Please join the conversations arising during and after the conference.

Karen Wyld is an author, consultant and freelance writer from South Australia. Of Aboriginal descent (Martu), she has a background in community development, social/health research, health workforce training, and Aboriginal community-controlled health. She currently has a draft novel long-listed for the 2017 Richell Prize. Read her recent articles for Al Jazeera, Monumental Errors, and for @IndigenousX: Ongoing administrative errors afflict the Indigenous Advancement Strategy. Follow on Twitter:  @1karenwyld

Aboriginal Primary Health Care Certificate 3 and 4 :@NSWTAFE ” Google School ” delivers to 38 Indigenous #NSW #QLD student graduates

Part of my job is to run clinics in the community, so having my Certificate IV qualification will allow me to check blood sugar, take blood samples and measure body mass index,”

Stephen Taylor from Nowra is studying this Certificate IV course to upskill in his job as an Aboriginal Community Support Worker and Chronic Care Coordinator, which involves monitoring the health of his clients thus minimising hospital visits. He believes these skills will increase his value to his community and to his employer

TAFE NSW Aboriginal Pathways students from across NSW and Queensland benefited from contemporary online learning during their recent studies in primary health care in Port Macquarie.

Originally published HERE

The students are studying the Certificate III or Certificate IV in Aboriginal and/or Torres Strait Islander Primary Health Care and are developing valuable skills like assessing clients’ physical wellbeing, administering medications, providing nutritional guidance, and addressing social determinants of health.

According to Sharon Taylor, Key Account Manager for Aboriginal Pathways TAFE NSW, this is not only the first time Certificate III and IV Practice qualifications in Aboriginal and/or Torres Strait Islander Primary Health Care have been held in Port Macquarie, but also the first time the qualifications have been delivered using the flexible technology of Google Classroom.

“Although they were all first time users, students and staff all spoke enthusiastically of this type of learning, highlighting as outstanding benefits the automatic saving function, online networking and collaborative features,” said Ms Taylor.

Both qualifications have a focus on culturally appropriate application, and workers in this industry are crucial to improving health outcomes for Aboriginal and Torres Strait Islander people.

Amarlee Kelly, one of the 38 students in the two classes, is an Aboriginal woman from Tweed Heads, in Bundjalung country on the north coast of NSW. For Ms Kelly, leaving family and country to study in Port Macquarie took her out of her comfort zone.

“I was very nervous and uncomfortable about leaving my husband,” said Ms Kelly.

“We have been married for 24 years, and we rarely do things without each other. [But] when Uncle Bill performed his amazing Welcome to Country, I was really able to get a feel for Birpai country, and after that I felt much more comfortable and was able to settle down and get to work.”

Ms Taylor added that with Australian Health Practitioner Regulation Agency (AHPRA) accreditation, TAFENSW Aboriginal Pathways are able to offer the Certificate IV in Aboriginal and/or Torres Strait Islander Practice qualification, which enables their graduates to become AHPRA- registered practitioners.

 

Aboriginal Health : Rhetoric to Reality: Devolving decision-making to Aboriginal communities

Delivering services to Aboriginal communities, in a way that involves them as genuine partners and produces effective results, remains an ongoing challenge for public services across Australia.

 ” There are three ways of dealing with people: you can do TO them, FOR them or WITH them. The historic experience for Aboriginal people is the done to, or done for, experience. We need to be doing it WITH them.”

As one of the participants in the research said:

Download the report here : rhetoric-to-reality-report

Delivering services to Aboriginal communities, in a way that involves them as genuine partners and produces effective results, remains an ongoing challenge for public services across Australia.

A new publication, developed by ANZSOG students in conjunction with the NSW Department of Aboriginal Affairs, looks at how the NSW public service can change the way it works with Aboriginal people and better devolve decision making to local communities.

Rhetoric to Reality: Devolving decision-making to Aboriginal communities focuses on what structural and attitudinal changes might be required to deliver better collaborative relationships with Aboriginal communities.

Interactions between Australian public services and Indigenous communities have historically been hampered by a lack of respect, trust and understanding.

The report finds that devolving decision-making to Aboriginal communities should not be seen as an end in itself. It should be a means of practising different ways of working with Aboriginal people that involve sharing knowledge and power, collaborating, and responding to local contexts. If this is done the ultimate result will be better shared outcomes for communities.

Whilst the Australian and international literature highlights many barriers to effective collaboration with Indigenous communities there are very few specific recommendations which go beyond ‘rhetoric’. Rhetoric to Reality provides a range of concrete approaches that NSW Government departments can consider.

 

Shift 1: Connecting to culture, connecting to Country

Key findings

The theme which emerged most clearly from our research was how important it is for public servants to develop and maintain genuine cultural competence. Almost all participants raised some aspect of cultural awareness or competence training as an example of what works and what does not.

Participants felt strongly that the current approach to cultural competence in the public service can be ad hoc, tokenistic, generic and static. Similarly, we found that ideas about cultural awareness, competence, safety or intelligence are not well articulated or understood in the NSW public service. The following statements provided by participants highlight these ideas:

“We’re underdone on comprehensive support for developing cultural competency.”

“I think we can all put our hand up, ‘Yep, job done,’ but then not actually spending any time with Aboriginal communities or adding on that extra layer to think about them.”

“Cultural competency training must be delivered in the most authentic way possible. It has to be real, practical and relevant for staff in their roles.”

“It needs to be honest and delivered by Aboriginal people.”

Research participants considered genuine cultural competence to be critical to changing public sector attitudes and structures. This finding is supported by the literature, which shows that cultural understanding (Zurba et al 2012) and culturally appropriate or safe service delivery (Thomas et al 2015) are important to building relationships with Aboriginal people. Studies have shown that a combination of practices can change structural racism in organisations (Abramovitz & Blitz 2015).

literature also supports the provision of cultural training for staff (Downing & Kowal 2011, Fredericks 2006, Paradies et al 2008). The limitations of cultural awareness training as a stand-alone activity were noted by our research participants and have been noted in previous research (e.g. Downing & Kowal 2011), including the risk of stereotyping, promoting ‘otherness’ and ignoring systemic responses. However, studies have shown it is possible to change prejudiced attitudes towards Aboriginal people through specific education activities (Finlay & Stephan 2000; Pendersen et al 2000 & 2004).

The local decision-making framework recognises that public servants need a level of cultural competence to participate. The Premier’s Memorandum M2015-01 Local Decision Making, states that “NSW agencies will adhere to the principles of local decision-making and ensure staff are educated to respond to the needs of Aboriginal communities in a culturally sensitive and appropriate manner”.

While cultural competence was recognised by our research participants and supported by the literature as a key enabler, the lack of a current framework for the development of genuine cultural competence by public servants persists as a dominant issue in shifting public service structural and attitudinal frameworks.

“The key is having a culturally competent NSW government.”

Below we note a number of recurring ideas for improvement in the understanding and the application of cultural competence in the public service that were raised by research participants.

Accepting that racism and paternalism still exist in the attitudes and structures of the public service and which may be manifested in ‘unconscious bias’ was noted by many participants: “It’s hard to accept we have unconscious bias because people in the public sector are values driven.”

Participants were candid about what they perceive as paternalistic views and subtle forms of racism and bias shown by individuals and institutions: “I believe government and its agencies a lack of faith and trust in Aboriginal people’s ability to make sound decisions in the best interest of their communities.”

Understanding history and the historical trauma experienced by Aboriginal people was viewed as critical. “From a community perspective there is a lot of historical hurt or pain from previous government decisions… You have to let them vent their anger and frustration of the historical decisions that have been made that have had a significant impact on their communities.”

“[A] lot of our staff don’t understand the stolen generation.”

Re-conceptualising cultural competence in the public service as a lifelong journey was seen by many participants as necessary for meaningful change. This includes real experience of working alongside Aboriginal people and communities, and ongoing reflective learning. “We need our staff to keep asking, ‘Why is that the case?’” This finding is supported by the literature, which notes that enhancing a person’s awareness of their biases is critical in reducing modern forms of prejudice and discrimination (e.g. Perry et al 2015).

Building trust was seen as vital. For example, participants talked about public servants, including senior public servants, taking the time before getting down to business to build relationships with Aboriginal people, by having a cuppa on neutral ground, listening and building rapport: “It may take a couple of meetings before you get down to the nitty gritty of developing your relationship with that community.” Building trust and developing genuine relationships were also a strong theme in the literature (Closing the Gap Clearinghouse 2015; Taylor et al 2013; Zurba et al 2012).

Including Country as critical to the development of cultural competence was a universal theme. Participants provided examples of how this could be achieved, including through site-based training, localised activities, travelling

The report’s three key recommendations are that:

  • Cultural competence is most effective when it is localised, ongoing and taught on-Country. Local communities could benefit from being engaged in this teaching.
  • Public-sector leaders who are fully committed to cultural competence are most likely to establish collaboration with Aboriginal communities as a routine approach within government. Examples of successful leadership of this kind should be recognised and publicised across the public sector.
  • Aboriginal public servants should be supported and nurtured, and should be seen as critically important for a culturally competent NSW public service.

Rhetoric to Reality was prepared as part of the capstone Work Based Project subject by ANZSOG Executive Master of Public Administration students Laura Andrew, Jane Cipants, Sandra Heriot, Prue Monument, Grant Pollard and Peter Stibbard. It exemplifies the quality of applied research conducted by ANZSOG’s EMPA students and the potential impact when our students partner with a government agency to help drive change.

The research involved interviews and focus groups with senior executives and frontline public servants in Sydney and regional NSW, to get their perspective on what needed to change to lift the impact of programs on the Aboriginal community.

All recognised the importance of cultural change, and the value of ensuring that successful programs, designed in partnership with local communities, were used as examples to improve results elsewhere.

Rhetoric to Reality will be available across the NSW public service as a valuable resource to ensure that government support for Aboriginal people delivers benefits to those communities.

NACCHO Aboriginal Health Research Alert : Comparisons of the characteristics of care in #ACCHOs and mainstream #PHC Primary Health Care

 ” Implications for public health: To increase utilisation of primary health care services in Indigenous Australian communities, and help close the gaps between the health status of Indigenous and non-Indigenous Australians, Indigenous community leaders and Australian governments should prioritise implementing effective initiatives to support quality health care provision by ACCHOs.

Download this research PDF

NACCHO Download What Indigenous Australian clients value

Abstract

Objective: To synthesise client perceptions of the unique characteristics and value of care provided in Aboriginal Community Controlled Health Organisations (ACCHOs) compared to mainstream/general practitioner services, and implications for improving access to quality, appropriate primary health care for Indigenous Australians.

Method: Standardised systematic review methods with modification informed by ethical and methodological considerations in research involving Indigenous Australians.

Results: Perceived unique valued characteristics of ACCHOs were: 1) accessibility, facilitated by ACCHOs welcoming social spaces and additional services; 2) culturally safe care; and 3) appropriate care, responsive to holistic needs.

Conclusion: Provider-client relationships characterised by shared understanding of clients’ needs, Indigenous staff, and relationships between clients who share the same culture, are central to ACCHO clients’ perceptions of ACCHOs’ unique value.

The client perceptions provide insights about how ACCHOs address socio-economic factors that contribute to high levels of chronic disease in Indigenous communities, why mainstream PHC provider care cannot substitute for ACCHO care, and how to improve accessibility and quality of care in mainstream providers.

Wide disparities remain between the health status of Aboriginal and Torres Strait Islander peoples (hereafter Indigenous Australians) and non-Indigenous Australians.1,2

Chronic diseases, including cardiovascular disease, diabetes and psychosocial illness caused by the history of colonisation, account for the bulk of the disparities.3

Inadequate access to primary health care (PHC) services responsive to Indigenous clients’ holistic needs, modifiable socioeconomic factors including low income, poor education, poor living conditions and social exclusion are principal contributors to the higher chronic disease burden in the Indigenous population.1–3 Increasing Indigenous Australian engagement with effective PHC, conceived in the comprehensive Indigenous Australian sense, is critical to reduce chronic disease in Indigenous communities and mitigate the disparities in health.3,4

Australia’s culturally diverse Indigenous peoples’ understanding of accessible, appropriate, quality PHC is different and broader than Western notions.3,5 From the Indigenous Australian perspective it is care conceived in the holistic Aboriginal way, that incorporates body, mind, spirit, land, environment, custom, socioeconomic status, family and community.5 The Indigenous Australian construct includes essential, integrated care based upon practical, scientifically sound and socially acceptable procedures and technology made accessible to communities as close as possible to where they live through their full participation in the spirit of self-reliance and self-determination and a comprehensive approach to supporting health.5

Importantly, all Indigenous Australians have the right to easily accessible, comprehensive, PHC delivered in a way that is respectful of Indigenous cultures, as well as to be involved in design and delivery of the PHC services they receive.6,7 International evidence investigating factors that increase accessibility and quality of PHC for Indigenous people, points to maximising community ownership and control, a robust indigenous managerial and clinical workforce, and the ability to deliver models of care that embrace Indigenous knowledge systems.3,8

Aboriginal Community Controlled Health Organisations (ACCHOs) are incorporated organisations, governed by boards of members elected by local Indigenous communities that aim to meet basic needs in Indigenous communities.5 ACCHOs function as knowledge and resource bases for Indigenous communities to advocate for their rights.5,9 The first ACCHO was established in 1971 in Redfern, in response to the failure of mainstream services to cater for the needs of its Indigenous peoples’ and desire for self-determination.5,9

By 2015 there were 138 ACCHOs in Australia 10 diverse with respect to their years of operation, budget and workforce sizes, and their governance, funding and service delivery models.10,11 Some ACCHOs employ medical practitioners and other staff, including Aboriginal Health Workers (AHWs) and provide a range of clinical and other services; others do not have a locally based medical practitioner, and rely only on AHWs.5,9,10 Assessments of health care quality based on Western informed measures have established that quality of clinical standards varies across ACCHOs and that many ACCHOs are achieving best practice standards.12

In addition to ACCHOs, state and territory funded Indigenous health organisations, which are concentrated in the Northern Territory and have varying degrees of community control, also play a role in providing culturally appropriate services in Indigenous communities.10 Of the 203 Indigenous PHC organisations in 2014/15, 68% were ACCHOs, 25% were government-run services, and 18% were mainstream non-government organisations.10Recent policy13 for improving Indigenous health in Australia reflects a strong commitment by government to implementing community control to enable better PHC quality and access, as well as to provide ACCHOs with the support they require to help achieve this goal. The policy commitment to building ACCHOs has been in place for more than 25 years.14

However implementation of the policy has been fraught with ongoing difficulties.11,14 ACCHOs rely on government funding, which they receive largely through three main Commonwealth sources: Medicare; contract funding for core PHC services; and contract funding for specific programs. Whilst some ACCHOs access the funding and workforce they require to deliver services that are responsive to community needs, and have been identified as offering exemplar models of care for Indigenous peoples15 the evidence relevant to the implementation of Indigenous control of health care in Australia,11,14,16–18 shows that many, particularly emerging organisations, struggle to navigate complex funding and accountability arrangements.

Evidence points to various inefficiencies in the funding and governance arrangements and questions their ability to support quality care provision that is responsive to each community’s unique needs and meets needs of all clients within communities.14In the context of increasing debate regarding the merits of mainstreaming Aboriginal PHC, we systematically reviewed qualitative evidence to document and understand how ACCHO clients perceive the characteristics and value of care provided by ACCHOs compared to care provided in mainstream PHC.

Our motivation was that the findings from existing qualitative studies, in academic and grey literature, on how ACCHO clients’ experience and perceive the nature and value of care provided in ACCHOs, and compared to in mainstream PHC services, had not yet been synthesised, yet synthesising the qualitative client perceptions might offer insights for health practitioners and policy makers on how best to improve Indigenous Australians’ access to PHC services that offer appropriate, quality care.

MethodThis review forms part of a larger systematic review project.19 We followed Joanna Briggs institute (JBI) guidance for systematic review of qualitative evidence20 and the PRISMA reporting guidelines.21 We took two steps to better align with ethical standards relevant to research involving Indigenous Australians22 and enable Indigenous specific contextual and cultural knowledge to inform the evidence appraisal and interpretation:23,24 1) Indigenous and non-Indigenous personnel were included in the review team; and 2) input was sought, at key stages in the review, from a reference group of Indigenous Australian community leaders and Indigenous people with expertise in PHC service delivery in Indigenous Australian communities.

Population and context: Indigenous clients (including family members, all ages) of ACCHOs.

Phenomena of interest: Perspectives on the characteristics and/or value of care provided by an ACCHO and the characteristics and/or value of care provided by one or more ACCHOs compared to the characteristics and value of care provided by one or more mainstream PHC services. ACCHOs were defined as non-government organisations operated by an Indigenous community, through an elected board of management. Mainstream providers were defined as general practitioner services. A service ‘characteristic’ was defined as a client identified attribute or feature of the PHC service, and a value as a client expressed experience of the worth or impact of the PHC service. Only perspectives evidenced by client voice were included.

Search and study selectionWe searched electronic sources for peer reviewed and grey literature studies meeting the inclusion criteria published in English, between April 1971 (date of first ACCHOs) and 30 April 2015. We searched the following databases using database specific search strings: Pubmed; Scopus; Healthbusinesselite; Econlit and Informit (Indigenous peoples databases).

Using generic search terms, we searched Google Scholar (advanced), Indigenous HealthInfoNet (Health Bibliography and Australian Indigenous Health Bulletin), Australian Policy Online, the Centre for Economic Policy website and Lowitja Institute websites. We hand searched references of two recent literature reviews, and the included studies. The search strategy is provided in Supplementary File 1, available online. The PubMed search string was:((health services, indigenous[mh] OR community health services[mh] OR primary health care[mh] OR rural health services[mh] OR community networks[mh] OR delivery of health care[mh] OR health planning[mh] OR community controlled health service*[tiab] OR indigenous health service*[tiab] OR community health service*[tiab] OR primary health care[tiab] OR rural health services[tiab] OR community networks[tiab] OR delivery of health care[tiab] OR health planning[tiab]) AND ((Aborig*[tw] OR Indigenous[tw] OR (Torres Strait[tw] AND Islander*[tw]) OR Oceanic Ancestry Group[mh] OR koori[tw] OR tiwi[tw]) AND (.au[ad] OR australia*[ad] OR Australia[mh] OR Australia*[tiab] OR Northern Territory[tiab] OR Northern Territory[ad] OR Tasmania*[tiab] OR Tasmania[ad] OR New South Wales[tiab] OR New South Wales[ad] OR Victoria*[tiab] OR Victoria[ad] OR Queensland[tiab] OR Queensland[ad]))) AND ((“1971/01/01”[PDat]: “2015/12/31”[PDat]))The search results were imported into an Endnote database (Thomson Reuters), where duplicates were removed. Title and abstract of the remaining records were then screened by JG for eligibility against the inclusion criteria, and full texts of potentially relevant studies set aside for further examination. JG, OG, DC independently reviewed the full-text articles against the inclusion criteria, noting reasons for exclusions. Uncertainty about whether the organisation was an ACCHO was resolved by contacting authors.

Quality assessment and data extractionWe used the critical appraisal and data extraction tools in the JBI Qualitative Assessment and Review Instrument (JBI-QARI).20 Two of the non-Indigenous authors (JG, DC) independently assessed quality of the studies that met the inclusion criteria, and two of the Indigenous Australian authors (OG, KK) crosschecked a 20% sample of the assessments for uniformity and accuracy. One reviewer (JG) extracted descriptive study data from the included studies. Three non-Indigenous members of the review team (JG, ZM, MS) extracted findings from the included studies for the phenomena of interest. Only client perceptions that were supported by an illustration, in the form of a client voice, were extracted. A 20% sample of the extracted findings was checked for accuracy by two of the Indigenous Australian authors (KO, OG). The confirmation of accuracy ensured that Indigenous Australian perspectives were applied in the quality appraisal and data extraction.

SynthesisWe used meta-aggregation20 to synthesise, separately, the client perceptions on the: 1) characteristics and value of care provided by ACCHOs; 2) characteristics of care provided by ACCHOs compared to mainstream PHC providers; and 3) value of care provided by ACCHOs compared to mainstream PHC providers. Meta-aggregation is grounded in the philosophic traditions of pragmatism and Husserlian transcendental phenomenology. The overall emphasis in this approach is on producing findings from existing studies that are credible in the sense that they reflect the meaning of the included studies, and inform practice-level lines of action that have applicability to healthcare policy or practice. Meta-aggregation embodies the complex nature of critical understanding, while ensuring the findings developed from the synthesis of study findings are meaningful and practical.20 For each synthesis, we followed the two-step thematic analysis approach of meta-aggregation. First, we developed categories of findings with similar meaning, and second, we developed synthesised findings describing the categories. To develop the categories, the first two authors (who led the synthesis), working independently, read and re-read the assembled findings with their supporting illustrations to understand their meaning, and grouped them into categories of similar findings, reflecting the main themes in the findings relating to the phenomena of interest.They then compared and discussed the two interpretations, and developed consensus-based categories of the identified themes.

To develop the synthesised findings, which in meta-aggregation represent overarching descriptions of the categories20, these same authors (OG and JG) first worked individually, and then together. OG’s interpretation of category meanings, and appropriate synthesised findings was privileged to ensure that the synthesised findings were informed by unique knowledge of Aboriginal and Torres Strait Islander culture and the context surrounding Aboriginal PHC, held by Indigenous Australians. AB guided the first author through the process of identifying the key cross-cutting themes in the synthesised findings, thereby ensuring that the second level analysis was also informed by Indigenous Australian expert knowledge. The draft categories, synthesised findings and interpretation of the themes emergent in the synthesised findings, were reviewed by all the other authors.
Results

Description of studies

Our search identified 4,405 records. From these, 816 duplicates were removed, leaving 3,589 for title and abstract screening against the review eligibility criteria. We excluded 3,468 of these for not meeting the inclusion criteria, leaving 112 for full text examination. Of these, six were not accessible, 19 did not offer findings for the phenomena of interest, 36 did not use qualitative methods, and for 51 we were uncertain whether participants were ACCHO clients. This left nine articles reporting nine studies. An additional article reporting one of the nine studies was identified in the references of one included article, resulting in 10 included articles,25,34 reporting nine studies. Supplementary file 2 provides the search results and study selection. The list of citations excluded at full text examination is available from the corresponding author.The results from the methodological quality assessment are provided in Supplementary file 3.

One was rated high quality,28 seven were rated good quality,27,29,34 and one, reported in two articles, was rated moderate quality.25,26 A lack of clarity about how researchers’ values and prior knowledge influenced studies was the main methodological concern potentially undermining the credibility of the findings that informed our syntheses. It is not possible without further information to comment on whether researchers’ values and knowledge enhanced the validity of findings or introduced bias.Details on the characteristics of each included study are provided in Supplementary File 4. All the studies were published between 2004 and 2014. Six used mixed methods.25–27,30,31,33,34 Four used focus groups and interviews,27,31–33 four used only interviews,25,26,28,30 and one used only focus groups. 34 Five of the studies adjusted their methodology to align with the unique ethical and methodological standards relevant to research with Indigenous Australians.28–30,33,34 Based on an estimation of 75 participants in one study that employed focus groups,27 a total of 811 study participants informed the meta-syntheses (including 640 from one study).31 There was good geographic representation in the ACCHO sample.

Synthesised findingsA diagrammatic representation of the three meta-aggregations of the ACCHO client perceptions is provided in Supplementary File 5.

Care in ACCHOsOur synthesis of the client perceptions on the characteristics and value of ACCHO care, extracted from the nine included studies,25–34 produced four synthesised findings.

Synthesised Finding 1: ACCHOs’ accessibility was highly valued. Clients identified ACCHOs’ transport services, proactive service provision, culturally safe care, range of services and welcoming environment as contributing to ACCHOs’ accessibility. Five categories informed this synthesised finding; each of them described a different characteristic that, from the clients’ perspective, contributed to accessibility. Proactive service provision was described as ACCHOs having outreach services (e.g. home visits), staff who were easily contactable, and staff meeting patients in public areas such as shopping centres.25–27 Culturally safe care was described as care delivered by providers who were good,28 who understood clients and knew how to meet their needs,29 who spent sufficient time with patients and who respected culture,29 in an environment that made clients feel comfortable.34 ACCHOs’ welcoming environment was described as including an emotional and relational dimension.27,29,33 The relational dimension was reflected in clients’ relating how they felt welcome in ACCHOs because they saw people who were familiar to them, and who understood them, both in the waiting room and in the clinical space.27,28 Clients indicated that they valued this because it gave them a sense of belonging.27,28 The emotional dimension of the welcoming environment was evidenced in descriptions of ACCHOs as social meeting places, where friends offered and received support.28,29 The following client voices are illustrative of how clients described ACCHOs’ welcoming environment:

“I just, just ah come here on my one day off and sit out here, have a talk with my mates…there’s always someone you know here… it’s a social event too…”29(p200)

“We share a lot. You know when you meet people you talk about things…If we go in and I know someone we’ll have a good yarn…?”29(p200)

Synthesised Finding 2: The way ACCHOs delivered care was highly valued. Clients valued staff taking the time to know and care for clients; personalised care tailored to self-perceived need; continuity of care; and appropriate communication. Clients related that they experienced feelings of belonging and confidence when accessing services with these service qualities. Four categories of findings informed this synthesised finding. The first was that clients experienced and valued staff, including doctors, taking their time with them.29 In the words of one client: “That’s the thing AMSs do really well, they take their time. There are not time limits”.29 ACCHOs providing healthcare in a personalised way tailored to client needs was the second category. These findings indicated that clients perceived ACCHOs as delivering care in a way that was responsive to their background27 by people who understood them.29 Clients also reported that the way staff provided care made them feel: known;29,33 less isolated (belonging);29,33 more confident;28 less anxious;30 cared for;30 accepted;28,29,30 supported;29 and encouraged.30 The third category was provision of information in a way that was understandable.27,30 Continuity of care was the last category, described as ongoing care and support for various problems in a client’s life over time.27,29

Synthesised Finding 3: Particular qualities of ACCHO staff were highly valued. These included Aboriginal identity of some of the ACCHO workforce, including AHWs; and staff who understood Indigenous clients and therefore behaved respectfully. Two categories informed this synthesised finding. The first was that clients valued the following behavioural qualities of staff: respectful and non-judgemental behaviour;27 staff taking time to know the client’s background and listen to their needs;29 sensitivity, kindness and reassurance;25,26 and trustworthiness.28,29 One said the way ACCHO staff allowed clients to talk about anything made you “feel at home”.27 The second category concerned how clients valued the Aboriginal identity of some ACCHO staff29,33 and the employment of AHWs.28 The following client voice illustrates how some clients described the value of AHWs:

“It was a whole new world…she was like a social worker I guess, we could talk to them individually, she was lovely. She explained everything, she took you in to how you know it all worked and was going to happen…you couldn’t have found so much difference between her, and the doctors who just tell you.”28(p6)

Synthesised Finding 4: A comprehensive, holistic approach to PHC was highly valued. The inclusion of non-clinical care, such as community events, group activities and enhanced supports available through community networks, had a positive impact on peoples’ wellbeing. Two categories informed this synthesised finding. The first was that non-clinical services, including ACCHOs’ social services, cultural events,33 and group activities such as diabetes camps30 and bush camps,33 were a valued characteristic. Clients pursued the opportunity group programs gave them to spend time with people who shared similar experiences, and to connect with community and culture.30,33 One client described the group-based activities as “a really great healing process”.33(p359) The second category of findings acknowledged and described perceived positive impacts of ACCHOs on client wellbeing.27,28,30,32 The impacts identified were: increased confidence;27,28 enhanced knowledge about how to manage conditions and actively engage in health decision making;30 pride in being part of the local Aboriginal community and its health service; better health;28,32 and better mental health.32

Comparisons of the characteristics of care in ACCHOs and mainstream PHC

Synthesis of the findings from three included studies contrasting the client perceptions of the characteristics of care in ACCHOs and mainstream PHC produced one synthesised finding which identified two differences between ACCHOs and mainstream PHC providers.28,29,33Synthesised Finding 5: While relationships were characterised by respect and understanding in ACCHOs, in mainstream services there was often a lack of respect and no shared understanding between providers and clients, or among clients. ACCHO clients described being discriminated against (also couched as being treated “differently”),28 patronised,28 assaulted and threatened29 by staff in mainstream services and contrasted this with staff in ACCHOs, including “behind the door in the clinical consultation space”,29 treating clients with respect and understanding rather than challenging or denying cultural identity.29 The second category was client-provider and provider-provider relationships in ACCHOs being characterised by high levels of trust,29 shared similar meanings29 and caring supportive relationships33 contrasting with a lack of mutual understanding and an absence of trust in the relationships within mainstream services.29
Comparisons of valued characteristics of care in ACCHOs and mainstream

Synthesis of findings from six of the included qualitative studies contrasting the value of care across the two sectors, identified three unique highly valued characteristics of care provided by ACCHOs compared to mainstream PHC providers.27–29,32–34

Synthesised Finding 6: ACCHO clients identified three unique highly valued characteristics of ACCHOs compared to mainstream PHC services: (1) accessibility, which clients described in terms of welcoming and safe spaces; (2) the way ACCHOs delivered care, in a culturally safe way tailored to need; and (3) comprehensive holistic care. The first point was that clients preferred ACCHOs because of their greater accessibility, which was related to additional services and their more welcoming environment.27,29,32,34 Clients described ACCHO waiting rooms as meeting and speaking environments “where people happen to be sick”,29 contrasted with mainstream services’ waiting rooms, described as quiet, formal sick places where you felt isolated.29 Clients signalled that relationships and support associated with companionship experienced in ACCHOs’ and Aboriginal staff were key to why ACCHOs were more accessible.32

“I used to go…all the way into [suburb] to see the AMS workers, and um I’d see a lot of people, it’s a great place to get together with a lot of people, a special place, and you see different ones, and have a yarn to…I’ve been away for a while, and um I always come back… In the [non-Indigenous] service you’re in, you’re out. There’s no friendliness…”28(p4–5)

“There’s always someone that you know, another family member or an old school chum or people you’ve played football with, and you’ve got that companionship there. If you were to go to the doctor’s surgery uptown and then just sitting there, oh god, I’m wishing to get out of there super quick.”33(p358)

“I was going to a doctor in Cleveland, and I didn’t feel comfortable there, but being here, where there’s other people around, yeah I felt comfortable when I came here the first time…there were Aboriginal nurses as well…and you could relate to them a bit more.32(p.6)

The second and third categories informing synthesised finding six, concerned differences in the way care was delivered across the two settings.27,29,3

Clients indicated they valued how staff in ACCHOs understood their holistic health care needs – signalled for example by references to be able to “talk to the AMS staff about anything and everything”– and were respectful,29(p202) and contrasted this with experiencing lack of understanding and inadequate care in mainstream PHC services.

Discussion

Our systematic review identified a small body of studies reporting qualitative data on client perceptions that when synthesised offers useful insights into how Indigenous clients view the nature and value of care provided in ACCHOs, and comparison to in mainstream PHC providers. Importantly, the findings from the syntheses contrasting care across the sectors mirrored those from the synthesis of clients’ perceptions of ACCHOs’ characteristics and value. Overall, our synthesis points to three unique, highly valued characteristics of care provided in ACCHOs compared to in mainstream providers. The first is ACCHOs’ unique accessibility. Clients perceive ACCHOs’ welcoming environment, which includes a social, emotional and physical aspect and supports cultural safety; ACCHOs’ flexible, responsive and proactive approach to care provision; and ACCHOs’ additional services, including transport and outreach as factors contributing to ACCHOs unique accessibility. The second unique, highly valued ACCHO characteristic is ACCHOs’ culturally safe care. This was described by clients as care delivered by staff, many Aboriginal, who feel known to clients, understand client needs and respect culture, in an environment where clients feels comfortable, supported and that they belong. The third was comprehensive care, that is, care responsive to holistic health needs.

Relationships, understanding and respect for culture central to clients’ view of accessible, appropriate, quality health care

High levels of trust and mutual understanding in the relationships between clients and health care providers, as well as close relationships between clients, were central themes in our syntheses. The presence of people from the local community, and involvement of Indigenous people in the service, was also central themes. Our synthesis therefore reinforces existing literature that has highlighted relationships,3,35 respect for culture and for Indigenous knowledge, and the involvement of Indigenous people in providing care, as central to Indigenous clients’ perceptions of accessible, appropriate and quality health care.

Why care provided by mainstream PHC providers will not substitute for ACCHO care

The description of ACCHOs’ characteristics and value compared to mainstream PHC providers highlights two distinct but equally important reasons why the care provided by mainstream providers cannot serve as a substitute for the care provided by ACCHOs for Indigenous clients. First, as has been previously noted,3 the characteristics of accessible and culturally safe care are such that mainstream PHC providers cannot achieve them using a tick-box approach and without fundamental change. Key elements, including the support offered by relationships amongst clients, will be difficult for mainstream providers to replicate. Second, mainstream services are not perceived by all Indigenous Australians as offering care that is responsive to holistic health needs. Moreover, mainstream PHC providers are ill-equipped to provide clients with a broad range of PHC programs tailored to self-perceived holistic health needs. They are focused on delivering clinical services designed largely to meet the needs of the majority, non-Indigenous population and to meet business objectives, and they are unlikely to transition to providing the additional services Indigenous Australians seek.

Additional insights on how ACCHOs improve Indigenous health

Our findings offer additional insights into the way ACCHOs contribute to improving the health and wellbeing of Indigenous Australians. Moreover, the clients’ references to positive impacts of ACCHOs on their confidence;27,28 on their knowledge about how to manage conditions and actively engage in health decision making;30 on their pride in being part of the local Aboriginal community and its health service; and on their mental health32 supports the conclusion of a recent review on ACCHOs’ impacts on Indigenous health,36 that ACCHOs are important not only because their health care helps to improve Indigenous Australians’ health, but also because of how they help to address the socioeconomic factors that contribute to high levels of chronic disease in Indigenous communities.

Strengths and limitations

The overall quality of the included studies was good. A second strength of our review is the steps we took to align our review methodology with the ethical and methodological requirements relating to research involving Indigenous Australians. These steps are important because they are called for by the unique standards for ethical research with Indigenous Australians, and because incorporating local contextual and cultural knowledge specific to Indigenous people adds to the credibility and relevance of the review findings and should aid their transferability into practice and policy.20,21

The small number of studies contributing to the syntheses, particularly the two comparing care across the sectors, is a limitation of our review. Neither the included ACCHO population nor the ACCHO client population were representations of their diverse total populations in Australia, potentially limiting the transferability of the findings. Another limitation relates to our inability (given data constraints) to explore potential variations in the perspectives of clients with different characteristics, e.g. males versus female, people of low and high socio-economic status. Third, whilst we did not extract findings from studies in which it was clear that the comparator was care in the hospital setting, we cannot be certain that references to “mainstream services” did not include this setting. We did not consider how clients’ perceptions of the characteristics and value of ACCHOs’ care compare with their perceptions of characteristics and value of other Indigenous PHC provider types. It is expected that Indigenous services, with high levels of local community involvement in the planning and delivery of their services, may be perceived by clients as having similar characteristics and value as ACCHOs. Fifth, there may be studies published since the end date of our search, that meet our review inclusion criteria, which may offer unique additional insights about how ACCHO clients perceive the characteristics and value of care provided by ACCHOs, and compared to mainstream providers, or they may confirm our synthesised findings.

Implications

Mainstream practitioners that seek to improve the accessibility and quality of their care for Indigenous peoples should: 1) invest in understanding Indigenous clients’ needs and learn how to be respectful of Indigenous clients’ culture; 2) adopt a flexible and proactive approach to providing care for Indigenous people (for example, they need to be prepared to meet clients outside of normal operating hours and engage in outreach activities); and 3) invest in making the clinic welcoming for Indigenous clients, for example, by putting up posters and other artefacts that are representative of Indigenous culture. However, for many Indigenous Australians, the care provided by mainstream PHC providers will not be a substitute for ACCHO care tailored to meet holistic health needs of Indigenous clients and their communities. Australian governments therefore should remain committed to the implementation of community control and should prioritise reforms to make the funding and accountability arrangements more enabling of rapid growth in the ACCHO sector and more supportive of high-quality, comprehensive, effective service provision by ACCHOs. To this end, government should look to the recommendations offered by recent research on barriers and facilitators regarding implementing Indigenous community control in PHC which offers useful guidance on reforms required in funding and accountability frameworks.11,14,16–18 In addition to building better funding and accountability arrangements for the ACCHO sector, governments need to continue to prioritise initiatives, for example best practice guideline development and dissemination, that enable all relevant treatments for comprehensive holistic health care being informed by scientific evidence. Ensuring that all ACCHOs have access to, and have the capacity to use, appropriate continuous quality improvement systems, for identifying their strengths and where system change is required to further strengthen the service and improve the health outcomes for clients accessing these services, is also important.37

Conclusion

The qualitative evidence on how Indigenous Australian ACCHO clients perceive the characteristics and value of care provided by ACCHOs, and compared to in mainstream PHC providers facilitates understanding why mainstream PHC provider care cannot be a substitute for ACCHO care. It also offers insights into how ACCHOs address socioeconomic factors that contribute to chronic disease in Indigenous communities. This sends a cautionary note to policy makers intent on mainstreaming Aboriginal PHC and underscores the importance of implementing the reforms to the funding and accountability arrangements for ACCHOs, that have been identified as important to support ACCHOs’ delivering quality services that are effective and meet holistic needs of clients in Indigenous communities. Mainstream PHC practitioners can learn from best-practice examples in the ACCHO sector how to improve the accessibility and quality of their care for Indigenous clients.

Acknowledgements

Judith Gomersall (JG), Odette Gibson (OG), Judith Dwyer (JD), Alex Brown (AB) and Edoardo Aromataris (EA) led the conceptualisation of the review. JG and OG led the writing of the protocol. The research governance group established to guide the work of the NHMRC Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange (CREATE) reviewed the protocol. JG performed the search and abstract review. OG, Drew Carter (DC) and EA conducted the full text examination. EA, an experienced systematic reviewer, provided oversight during the search and study selection process. EA and Zachary Munn (ZM) provided technical advice about appropriate review method. Two non-Indigenous Australian members of the review team, DC and JG, assessed the quality of studies. Their assessments were reviewed by two Indigenous Australian members of the team, OG and Kootsy Kanuto (KK). Matthew Stephenson (MS), ZM and JG (all non-Indigenous Australians) extracted the data from the included studies. Two Indigenous members of the review team, OG and Kim O’Donnell (KO), reviewed their data extraction. KO, OG, MS, JG and DC participated in a workshop convened to develop an initial set of categories for the meta-aggregation. OG and JG then worked together on the meta- aggregation with OG’s perspective being privilege due to her unique insider Aboriginal knowledge. AB, a senior Indigenous Australian health researcher with expert knowledge of Aboriginal health and the Aboriginal health sector, guided JG through the second level analysis, the interpretation of the synthesised findings. JG, OG JD and EA led the writing of the paper, which was reviewed by all authors. The findings of the review were presented to representatives of the CREATE leadership group prior to submission of this article for publication, and feedback received integrated. The authors thank the participants of the CREATE leadership group for the invaluable guidance and time they provided during this review. We also thank Harold Stewart and Stephen Harfield for participating in the workshop held at the beginning of the synthesis stage of the review. Finally, we thank Sandeep Moola for assistance during the data extraction stage of the review.

Funding

The NHMRC (GNT1061242) supported this project. The contents of the published material are solely the responsibility of the Administering Institution, a Participating Institution or individual authors and do not reflect the views of NHMRC.

NACCHO Aboriginal Health #NAIDOC2017 @TheMJA —Embedding cultural safety in Australia’s main health care standards

 ” Cultural safety requires embedding in not only course accreditation for each health profession — including measures to reduce resistance — but also in the standards governing clinical professionalism and quality, such as the Royal Australian College of General Practitioners Standards for general practices,19 and the Australian Commission on Safety and Quality in Health Care National safety and quality health service standards.20

Such commitment will need investment in clinician education and professional development, together with measures for accountability. The stewards of the National Aboriginal and Torres Strait Islander Health Plan5 (ie, the Department of Health and their expert implementation advisory group), accreditation bodies, and monitors of the existing frameworks of safety and quality standards in health care need to formally collaborate on a systematic revision of standards to embed culturally safe practice and develop health settings free of racism.”

Martin Laverty, Dennis R McDermott and Tom Calma

Originally published by MJA here

Download a PDF of this Report Paper for references 1-20

MJA Cultural Safety

Read 20 + previous NACCHO articles Cultural Safety  

In Australia, the existing health safety and quality standards are insufficient to ensure culturally safe care for Indigenous patients in order to achieve optimum care outcomes.

Where “business as usual” health care is perceived as demeaning or disempowering — that is, deemed racist or culturally unsafe — it may significantly reduce treatment adherence or result in complete disengagement,1,2 even when this may be life-threatening.3

Peak Indigenous health bodies argue that boosting the likelihood of culturally safe clinical care may substantially contribute to Indigenous health improvement.4 It follows that a more specific embedding of cultural safety within mandatory standards for safe, quality-assured clinical care may strengthen the currently inadequate Closing the Gap mechanisms related to health care delivery.

The causes of inequitable health care are many. Western biomedical praxis differs from Indigenous foundational, holistic attention to the physical, emotional, mental and spiritual wellbeing of the person and the community.5 An article published in this issue of the MJA6 deals with the link between culture and language in improving communication in Indigenous health settings, a critical component of delivering cultural safety.

Integrating cultural safety in an active manner reconfigures health care to allow greater equity of realised access, rather than the assumption of full access, including procession to appropriate intervention.

As an example of the need to improve equity, a South Australian study found that Indigenous people presenting to emergency departments with acute coronary syndrome were half as likely as non-Indigenous patients to undergo angiography.7 More broadly, Indigenous people admitted to hospital are less likely to have a procedure for a condition than non-Indigenous people.8

Cardiovascular disease is the leading cause of death in Indigenous Australians.9 Cancer is the second biggest killer: the mortality rate for some cancers is three times higher for Indigenous than for non-Indigenous Australians.10 Clinical leaders in these two disease areas have identified the need for culturally safe health care to improve Indigenous health outcomes.

Cultural safety is an Indigenous-led model of care, with limited, but increasing, uptake, particularly in Australia, New Zealand and Canada. It acknowledges the barriers to clinical effectiveness arising from the inherent power imbalance between provider and patient,11 and moves to redress this dynamic by making the clinician’s cultural underpinning a critical focus for reflection.

Moreover, it invites practitioners to consider: “what do I bring to this encounter, what is going on for me?” Culturally safe care results where there is no inadvertent disempowering of the recipient, indeed where recipients are involved in the decision making and become part of a team effort to maximise the effectiveness of the care. The model pursues more effective practice through being aware of difference, decolonising, considering power relationships, implementing reflective practice, and by allowing the patient to determine what safety means.11

Along with an emphasis on provider praxis, cultural safety focuses on how institutional care is both envisaged and delivered.12 Literature on cultural safety in Australia is scant but growing.13 Where evidence is available, it identifies communication difficulties and racism as barriers not only to access but also to the receipt of indicated interventions or procedures.11

There is evidence of means to overcome these barriers. An Australian study undertaken across ten general practices tested the use of a cultural safety workshop, a health worker toolkit, and partnerships with mentors from Indigenous organisations and general practitioners.13 Cultural respect (significant improvements on cultural quotient score, along with Indigenous patient and cultural mentor rating), service (significant increase in Indigenous patients seen) and clinical measures (some significant increases in the recording of chronic disease factors) improved across the participating practices.

In addition, a 2010 study by Durey14 assessed the role of education, for both undergraduate students and health practitioners, in the delivery of culturally responsive health service, improving practice and reducing racism and disparities in health care between Indigenous and non-Indigenous Australians. The study found that cultural safety programs may lead to short term improvements to health practice, but that evidence of sustained change is more elusive because few programs have been subject to long term evaluation..

Newman and colleagues10 identified clinician reliance on stereotypical narratives of indigeneity in informing cancer care services. Redressing these taken-for-granted assumptions led to culturally engaged and more effective cancer care. In a similar manner, Ilton and colleagues15 addressed the importance of individual clinician cultural safety for optimising outcomes, noting that provider perceptions of Indigenous patient attributes may be biased toward conservative care.

The authors, however, went beyond the clinician–patient interaction to stress the outcome-enhancing power of change in the organisational and health setting. They proposed a management framework for acute coronary syndromes in Indigenous Australians.

This framework involved coordinated pathways of care, with roles for Indigenous cardiac coordinators and supported by clinical networks and Aboriginal liaison officers. It specified culturally appropriate warning information, appropriate treatment, individualised care plans, culturally appropriate tools within hospital education, inclusion of families and adequate follow-up.

Willis and colleagues16 also called for organisational change as an essential companion to individual practitioner development. Drawing on 12 studies involving continuous quality improvement (CQI) or CQI-like methods and short term interventions, they acknowledged evidence gaps, prescribing caution, and argued for such change to be undertaken in the service of long term controlled trials, as these would require 2–3 years to see any CQI-related changes.

Sjoberg and McDermott,17 however, noted the existence of barriers to change: the challenge (personal and professional) posed by Indigenous health and cultural safety training may not only lead to individual but also to institutional resistance.17 Dismantling individual resistance requires the development of a critical disposition — deemed central to professionalism and quality18 — but in a context of strengthened and legitimating accreditation specific to each discipline. The barriers thrown up by institutional resistance, manifesting as gatekeeping, marginalisation or underfunding, may require organisational change mandated by standards.

NACCHO Aboriginal Health #CarersGateway : Free online resources to support #Aboriginal #carers

It’s rewarding work, but without help Dolly finds herself emotionally and physically drained. Dolly reached out and found that she could get services to help her.

Like Dolly, millions of people in Australia care for others who need help with their everyday lives.

A carer may be someone who looks after their husband or wife, partner, grandparent, uncle, aunty, cousin, child, grandchild or any other family member, a neighbour, a friend or someone in their community who needs help.

Everyone’s situation is different. Some carers look after someone who is an older person or who is unwell or has difficulties getting around. Some carers may look after someone who has a disability, a mental illness or dementia, a chronic condition or a long-term illness or drug and alcohol problems.

Many people looking after someone else don’t think of themselves as carers. They just see caring as what they do to help their families or friends or people in their communities.

Carers need help too – someone they can talk to and find out about services that can help. Carer Gateway is a free, Australian Government funded service that provides information for carers and helps people get in touch with their local services. People can ring up and have a private chat or go online and find out about support in their area, free financial and legal help and what to do in emergencies.  They can also get tips on how to look after themselves so they don’t get burnt out while caring for someone else.

Carer Gateway has short videos about real-life carers in the community – showing how they cope and deal with problems – and how they make the most of the time they spend caring for someone in need.

The videos include Dolly’s story. Dolly is a mother and full-time carer for her two adult daughters, who both need support with their everyday needs.

“It’s pretty much 24/7 around the clock. Four years ago, I realised I was doing a care role and I was also a working mum so quite busy. I thought you know what, it’s time for me to step back and start looking after my own,” she said.

There are free online resources to support Aboriginal carers, including a guided relaxation audio recording and information brochures and posters for use by health and community groups  which can also be ordered from the Carer Gateway ordering form and a Carer Gateway Facebook page to keep up to date on services and supports for carers.

To find out more, Carer Gateway can be contacted on 1800 422 737, Monday to Friday between 8am and 6pm,

or by visiting carergateway.gov.au

You can join the Carer Gateway Facebook community by visiting https://www.facebook.com/carergateway/

 

 

 

Aboriginal Health : Second Atlas of Healthcare Variation highlights higher Aboriginal hospitalisation rates for all 18 clinical conditions

 

“The report, compiled by the Australian Commission on Safety and Quality in Health Care, shows us that high hospitalisation rates often point to inadequate primary care in the community, leading to higher rates of potentially preventative hospitalization

The most disturbing example of this  has been the higher hospitalisation rates for all of the 18 clinical conditions surveyed experienced by Aboriginal and Torres Strait Islander Australians, people living in areas of relative socioeconomic disadvantage and those living in remote areas.

 Chairman of Consumers Health Forum, Tony Lawson who is a member of the Atlas Advisory Group.

 “Additional priorities for investigation and action are hospitalisation rates for specific populations with chronic conditions and cardiovascular conditions, particularly:

  • Aboriginal and Torres Strait Islander Australians
  • People living in remote areas
  • People at most socioeconomic disadvantage.

Please note

  • Features of the second Atlas include: Analysis of data by Aboriginal and Torres Strait Islander status

DOWNLOAD Key-findings-and-recommendations

Mr Martin Bowles Secretary Dept of Health  launches the Second Australian Atlas of Healthcare Variation

A new report showing dramatic differences in treatment rates around Australia signals a pressing need for reforms to ensure equitable access to appropriate health care for all Australians, the Consumers Health Forum, says.

“A seven-fold difference in hospitalisation for heart failure and a 15-fold difference for a serious chronic respiratory disease depending on place of residence, are among many findings of substantial variations in treatment rates in Australia revealed in the Second Australian Atlas of Healthcare Variation,” the chairman of Consumers Health Forum, Tony Lawson, said.

“While there are a variety of factors contributing to these differences,  the variation in health and treatment outcomes is, as the report states, an ‘alarm bell’ that should make us stop and investigate whether appropriate care is being delivered.

“These findings show that recommended care for chronic diseases is not always provided.  Even with the significant funding provided through Medicare to better coordinate primary care for people with chronic and complex conditions, fragmented health services contribute to suboptimal management, as the report states.

“We support the report’s recommendation for a stronger primary health system that would provide a clinical ‘home base’ for coordination of patient care and in which patients and carers are activated to develop their knowledge and confidence to manage their health with the aid of a healthcare team.

“The Atlas provides further robust reasons for federal, state and territory governments to act on the demonstrated need for a more effective primary health system that will ensure better and more cost effective care for all Australians.

“The Atlas also examined  variations in women’s health care, and its findings included a seven-fold difference in rates of hysterectomy and  21-fold  difference in rates of endometrial ablation.  The report states that rates of hysterectomy and caesarean sections in Australia are higher than reported rates in other developed nations.  These results highlight the need for continuing support and information on women’s health issues,” Mr Lawson said.

The Second Australian Atlas of Healthcare Variation (second Atlas) paints a picture of marked variation in the use of 18 clinical areas (hospitalisations, surgical procedures and complications) across Australia.

This Atlas, the second to be released by the Commission, illuminates variation by mapping use of health care according to where people live.  As well, this Atlas identifies specific achievable actions for exploration and quality improvement.

The second Atlas includes interventions not covered in the first Atlas, such as hospitalisations for chronic diseases and caesarean section in younger women. It also builds on the findings from the first Atlas – for example, examining hysterectomy and endometrial ablation separately, and examining rates of cataract surgery using a different dataset.

Priority areas for investigation and action arising from the second Atlas include use of:

  • Hysterectomy and endometrial ablation
  • Chronic conditions (COPD, diabetes complications)
  • Knee replacement.

Additional priorities for investigation and action are hospitalisation rates for specific populations with chronic conditions and cardiovascular conditions, particularly:

  • Aboriginal and Torres Strait Islander Australians
  • People living in remote areas
  • People at most socioeconomic disadvantage.

Healthcare Variation – what does it tell us

Some variation is expected and associated with need-related factors such as underlying differences in the health of specific populations, or personal preferences. However, the weight of evidence in Australia and internationally suggests that much of the variation documented in the Atlas is likely to be unwarranted. Understanding this variation is critical to improving the quality, value and appropriateness of health care.

View the second Atlas

The second Atlas, released in June 2017, examined four clinical themes: chronic disease and infection – potentially preventable hospitalisations, cardiovascular, women’s health and maternity, and surgical interventions.

Key findings and recommendations for action are available here.

View the maps and download the data using the interactive platform.

What does the Atlas measure?

The second Atlas shows rates of use of healthcare interventions (hospitalisations, surgical procedures and complications,) in geographical areas across Australia.  The rate is then age and sex standardised to allow comparisons between populations with different age and sex structures. All rates are based on the patient’s place of residence, not the location of the hospital or health service.

The second Atlas uses data from national databases to explore variation across different healthcare settings. These included the National Hospital Morbidity Database and the AIHW National Perinatal Data Collection.

Who has developed the second Atlas?

The Commission worked with the Australian Institute of Health and Welfare (AIHW) on the second Atlas.

The Commission consulted widely with the Australian government, state and territory governments, specialist medical colleges, clinicians and consumer representatives to develop the second Atlas.

Features of the second Atlas include:

  • Greater involvement of clinicians during all stages of development
  • Analysis of data by Aboriginal and Torres Strait Islander status
  • Analysis of data by patient funding status (public or private).

Table of Contents

Chapter 1 Chronic disease and infection: potentially preventable hospitalisations

1.1 Chronic obstructive pulmonary disease (COPD)
1.2 Heart failure
1.3 Cellulitis
1.4 Kidney and urinary tract infections
1.5 Diabetes complications

Chapter 2 Cardiovascular conditions

2.1 Acute myocardial infarction admissions
2.2 Atrial fibrillation

Chapter 3 Women’s health and maternity

3.1 Hysterectomy
3.2 Endometrial ablation
3.3 Cervical loop excision or cervical laser ablation
3.4 Caesarean section, ages 20 to 34 years
3.5 Third- and fourth-degree perineal tear

Chapter 4 Surgical interventions

4.1 Knee replacement
4.2 Lumbar spinal decompression
4.3 Lumbar spinal fusion
4.4 Laparoscopic cholecystectomy
4.5 Appendicectomy
4.6 Cataract surgery
Technical Supplement
About the Atlas
Glossary

Australian Atlas of Healthcare Variation data set specifications are available at http://meteor.aihw.gov.au/content/index.phtml/itemId/674758