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


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.

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.


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.


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


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.


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.


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

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


NACCHO Aboriginal Health #NRW2017 Elder Care : Audit report Aged Care services were delivered to 35 083 Indigenous elders


 ” Health conditions associated with ageing often affect Aboriginal and Torres Strait Islander people earlier than other Australians.3

This is reflected in the Australian Government policy to provide Aboriginal and Torres Strait Islander people access to aged care services from 50 years old, in comparison to 65 years old for the broader population.

Aboriginal and Torres Strait Islander people are also designated as a special needs group under the Aged Care Act 1997 and all aged care service providers must have regard to the particular physical, physiological, social, spiritual, environmental and other health related care needs of individual recipients.4″

From ANAO Audit report Download here

Dep of Health Audit report Indigenous Aged Care

Image above from here


1. The Australian Government provided $15.2 billion in funding to the aged care sector in 2014–15 and $16.2 billion in 2015–16.

Aged Care services were delivered to 35 083 Aboriginal and Torres Strait Islander people in 2014–15 at an estimated cost of $216 million1 (approximately 1.4 per cent of the total aged care budget).2

2. See above intro 4

3. The Australian Government funds aged care services to assist frail older people, and the carers of frail older people, to remain living at home as well as residential aged care services. The programs funded include:

  • the Commonwealth Home Support Program, which provides entry-level home support for older people who need assistance to keep living independently;
  • the Home Care Packages Program, which provides services tailored to meet individuals’ specific care needs including care services, support services, clinical services and other services to support older people to remain living at home and connected to their communities; and
  • residential aged care, which provides supported accommodation services for older people who are unable to continue living independently in their own homes.

4. Aboriginal and Torres Strait Islander people also have access to aged care services funded through the National Aboriginal and Torres Strait Islander Flexible Aged Care Program (Flexible Program). In 2015–16 funding for the Flexible Program was approximately $37 million, based on agreed funded places rather than occupancy. The Flexible Program aims to provide aged care services that meet the specific needs of Aboriginal and Torres Strait Islander people in a culturally appropriate setting, close to home and community. The majority of Flexible Program services are delivered in regional, remote and very remote locations.5

5. The Department of Health is responsible for leading the development of evidence based policy, determining the allocation of funding, and regulation of the Commonwealth aged care system to improve the wellbeing of older Australians as well as the implementation of the aged care reforms. The Australian Aged Care Quality Agency is responsible for assessing the quality of care of Australian Government funded aged care service providers. This is done through:

  • the accreditation of residential aged care service providers;
  • quality reviews of aged care provided to people living in their own homes or in the community; and
  • education and training on quality aged care to the aged care sector.

Audit objective and criteria

6. The objective of the audit was to assess the effectiveness of Australian Government-funded aged care services delivered to Aboriginal and Torres Strait Islander people. To form a conclusion against the audit objective, the ANAO adopted the following high level criteria:

  • Is there an effective framework in place to support access by Aboriginal and Torres Strait Islander people to quality aged care services?
  • Do the Department of Health and the Australian Aged Care Quality Agency have effective frameworks to oversee the delivery of aged care services to Aboriginal and Torres Strait Islander people?
  • Does the Department of Health have appropriate arrangements in place for monitoring and reporting on the achievement of program objectives and supporting the cost effectiveness and service continuity of aged care delivery to Aboriginal and Torres Strait Islander people?


7. Australian Government-funded aged care services are largely delivered effectively to Aboriginal and Torres Strait Islander people.

8. The ageing of Australia’s population and growing diversity among older people, in terms of their care needs, preferences and socioeconomic status, are placing pressure on the depth and agility of Australia’s aged care system. There are additional challenges in ensuring access to culturally appropriate care and service continuity for Aboriginal and Torres Strait Islander people, particularly for those living in remote and very remote communities. Some Aboriginal and Torres Strait Islander people may also have language or cultural preferences that influence their specific requirements.

9. The National Aboriginal and Torres Strait Islander Flexible Aged Care Program has been effective in increasing the access to culturally appropriate aged care services for elderly Indigenous Australians. The direct selection and recurrent funding approach of the National Aboriginal and Torres Strait Islander Flexible Aged Care Program provides few opportunities for new service providers to enter the market. There would be benefit in the Department of Health extending the application process to new service providers and better aligning the funded places with service capacity.

10. The Department of Health has developed sufficient guidance materials and provides supplementary funding to support Indigenous-focused services that operate under the Commonwealth Home Support, Home Care Packages and residential programs. However, not all Indigenous-focused services are aware of the Department of Health’s sector support programs.6

11. The Department of Health and the Australian Aged Care Quality Agency have been largely effective in their administration of Australian Government-funded aged care services delivered to Aboriginal and Torres Strait Islander people. Each entity has developed sound administrative arrangements to manage the delivery of aged care services and to review the quality of care delivered through aged care programs. The Department of Health can strengthen its administration by implementing a coordinated approach that ensures the timely sharing of relevant information to facilitate risk assessments across the Ageing and Aged Care Group.

12. Consistent with its policy intent, the National Aboriginal and Torres Strait Islander Flexible Aged Care Program is a more cost effective and viable model for specialised aged care delivery to Indigenous Australians when services are located in remote and very remote communities. A 25.8 per cent share of National Aboriginal and Torres Strait Islander Flexible Aged Care Program funding is allocated to services located in major cities and inner regional areas. To optimise recurrent funding decisions, it is important the Department of Health ensures that the existing service providers, their location and number of places, remain the most appropriate.

13. Given that the majority of Aboriginal and Torres Strait Islander people access aged care through Commonwealth Home Support Program, Home Care Packages Program and residential aged care programs, further work is required by the Department of Health to maintain the service continuity of Indigenous-focused service providers in areas where there are no culturally secure alternatives. The Department of Health has an opportunity to leverage its datasets to improve the targeting of sector support initiatives to Indigenous-focused services and to monitor the ongoing impacts of aged care policies and programs on Aboriginal and Torres Strait Islander people.

Supporting findings

Access and use of aged care services by Aboriginal and Torres Strait Islander people

14. Aboriginal and Torres Strait Islander people were most likely to access aged care services through the Commonwealth Home Support Program or the Home Care Packages Program, at rates consistent with their share of the aged care population. Fewer than one per cent of residential aged care places were taken up by Aboriginal and Torres Strait Islander people.

15. The Department of Health has created clear and consistent pathways for individuals to access and progress through the aged care system. The My Aged Care Contact Centre and website are the main entry points to the aged care system. Aboriginal and Torres Strait Islander people are encouraged to connect with the My Aged Care Contact Centre, and can call directly or use a trusted representative to speak on their behalf. Following an initial screening undertaken by Contact Centre staff, the Regional Assessment Service assesses older people’s needs for lower intensity services available under the Commonwealth Home Support Program. Aged Care Assessment Teams assess the more complex needs of people requiring access to higher intensity care available under Home Care Packages, Transition Care, and within residential aged care.

16. A key challenge in targeting aged care services is assessing the eligibility of individuals seeking to access them as well as the scope of services. This can be particularly challenging in the context of facilitating access for individuals in remote or very remote areas, including Aboriginal and Torres Strait Islander people.

17. The Department of Health advised the ANAO that it is working with the aged care sector to identify opportunities to improve client pathways for diverse groups, including Aboriginal and Torres Strait Islander people, to address the specific difficulties they may experience.

18. The Department of Health manages the planning and allocation of aged care residential places and Home Care packages for service providers based on the national planning benchmark, population projections and the current level of service provision. The Commonwealth Home Support Program and the National Aboriginal and Torres Strait Islander Flexible Aged Care Program are funded through a grants process.

19. Between 2012–13 and 2015–16 the number of Home Care Level 1‒2 packages allocated to Indigenous-focused service providers has not grown at the same rate as those allocated to mainstream service providers. However, the growth in Home Care Level 3‒4 package and residential place allocations to Indigenous-focused service providers have both been higher than for mainstream counterparts.

20. The distribution of the National Aboriginal and Torres Strait Islander Flexible Aged Care Program funding has remained largely unchanged since its inception. This is largely due to the continuation of grant agreements to existing services that have been in place over the life of the program. These arrangements limit the potential for new providers to access the program.

21. The Department of Health has developed operational manuals and/or guidelines to support providers in the delivery and management of aged care services for the programs reviewed as part of the audit. The Department of Health also funds two peak bodies to develop additional resources to assist with managing the change introduced by aged care reforms (including resources targeted towards remote and very remote Indigenous-focused service providers).

22. The Department of Health funds a Remote and Aboriginal and Torres Strait Islander Aged Care Service Development Assistance Panel (SDAP) to support aged care providers. ANAO consultations with Indigenous-focussed service providers indicated that awareness of SDAP funding varied across states and territories. There would be benefit in the Department of Health raising the awareness of this assistance in a consistent manner across jurisdictions, and measuring the financial management and governance capacity that has been built and maintained among service providers as a result of having received the funding.

Administration and regulation of aged care services

23. The Department of Health has internal governance committees, templates and guidance to coordinate program administration. Health’s state and territory offices have also adopted various local strategies for engaging with Indigenous-focused service providers. The department has commenced work to strengthen relationships between its National Office and its state and territory offices, to improve links between policy development and program implementation, while still allowing for specific approaches within each jurisdiction.

24. The Department of Health has developed an Enterprise Risk Management Plan that is updated annually as part of the department’s business planning processes. Each of the programs reviewed as part of the audit included risk management (identification, analysis and evaluation) in its business processes. Risk is considered against the type of activity being funded and may result in different risk ratings being given to the same organisation across each activity or program being funded. For service providers that are funded under multiple programs, there is an opportunity for Health to implement a more coordinated approach that facilitates the timely sharing of relevant information across program areas.

25. The Australian Aged Care Quality Agency has developed policies, procedures and guidance materials to support the accreditation of residential aged care service providers, and specific policies for the quality review of Home Care Packages, Commonwealth Home Support Program and National Aboriginal and Torres Strait Islander Flexible Aged Care Program service providers. Documents reviewed by the ANAO demonstrate that the relevant accreditation and quality review procedures were followed internally.

26. The Australian Aged Care Quality Agency has collected information on assessments of all residential service providers against the accreditation standards. This information shows that between 2000-01 and 2015-16, 95 per cent of residential Indigenous-focused service providers had at least one episode of non-compliance, in comparison with 53 per cent of non-Indigenous-focused Residential service providers. Reported instances of non-compliance mostly related to governance, including regulatory compliance, risk management and human resources as opposed to issues relating to quality of care.

27. In 2014–15 the Australian Aged Care Quality Agency delivered 716 courses, seminars and compliance assistance training events to 10 638 participants from residential and Home Care service providers. Flexible service providers receive compliance assistance training as determined through a case management process. There would be benefit in the Australian Aged Care Quality Agency expanding the proposed cost recovery model to include the indirect and direct costs recovered from courses and workshops to be consistent with the Australian Government’s stated policy intention, as well as the Australian Government Cost Recovery Guidelines.

NACCHO Aboriginal Health Summary #ruralhealthconf : Indigenous health focus at 14th National Rural Health Conference

As we contemplate a culturally safe future from our current vantage point, let us reflect upon how each and every one of us can contribute to making this future that I’ve shared with you today a reality.

  • Embed cultural safety in your organisation’s strategic plan, and Reconciliation Action Plan.
  • Make anti-racism practice part of your everyday – whether you are at home or at work – and whether anyone is looking or not. Enact zero tolerance for racism.
  • Ensure your governance structures reflect the communities who you are serving. Privilege the voices and the wisdom of Aboriginal and Torres Strait Islander people and organisations.
  • Inform yourself about 18C and Constitutional Recognition.
  • Inform yourself about climate change and the actions you can take – and try to put aside non-Indigenous lenses when doing this. Learn from us about caring for country.
  • Practise trust, respect and reciprocity. Build and value your relationships with us

In 2037, let us look back on this conference – and this moment – as a time when we stood together, determined to make history and to create a better future.”

It’s no wonder the speech  ” Today is tomorrow’s history ”  from Janine Mohamed – CEO of the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) – sparked such a big response at the National Rural Health Conference in Cairns.

She imagined a strong, positive, future for Australia 20 years from now – and what it might take to get us there.

See full speech below thanks to Janine and Croakey Team

The improvement of Indigenous health outcomes in rural and remote areas was the focus of many of the sessions and keynote presentations at the 14th National Rural Health Conference in Cairns .

Dr Mark Wenitong, Senior Medical Advisor with the Apunipima Cape York Council, spoke on health and cultural competence.

Addressing matters such as clinicians bringing their own cultural biases into practices, DrWenitong stressed the need for individuals to learn more about their own cultures.

“Reflective practice is important so that people recognise their own bias,” he said, also pointing out that some of the simplest are the most effective.

“You need to treat people nicely and with respect to improve engagement.”

Download  Cultural competency in the delivery of health services for Indigenous people referenced by Dr Mark Wenitong ctgc-ip13

Another of the keynote presenters was Professor of Nursing and Midwifery at CQ University, Gracelyn Smallwood.

Professor Smallwood discussed the need to better understand history in order to aid reconciliation.

“Captain Cook didn’t discover Australia. People were here for thousands of years and one day discovered Captain Cook.”

Audience member Dr Lucas de Toca tweeted that Professor Smallwood was perceived as “Absolutely killing it delivering hard truths in her outstanding keynote on cultural competency at #ruralhealthconf.”

The Assistant Minister for Health, Dr David Gillespie was present for the conclusion of proceedings and to receive the priority recommendations for rural and remote health to emerge from the Conference as put forward by the attending delegates through the Sharing Shed.

See all recommendations here DOWNLOAD



Janine Mohamed: speech to the National Rural Health Conference

As published originally here thanks to Janine and Croakey Team

Good morning ladies and gentlemen, Elders, dignitaries and colleagues.

janineI would like to begin by paying my respects to the Traditional Custodians of this land, the Yirrganydji Gimyayg Yidinji people, and to Elders past and present, and future generations.

Thank you for your very warm welcome and for the invitation to talk to you today.

About two years ago I had the privilege of meeting Professor Moana Jackson, from Aeoteroa. He is truly an inspirational Maori leader, who challenged us at CATSINaM to ‘see beyond the mountain’, to vision our future at all costs, and to be brave because that is the way of our people.

He also reminded us that we are storytellers – Moana has inspired me to share our hopes for the future with you today.

So….hang on to your seats – we are going to be doing some time travel together!

Becoming advocates and agents of change

slide young JanineWhen I was a young girl I realised I wanted to become a nurse, after seeing my family members suffer traumatic experiences at the hands of the health system.

While I have worked in many different roles across the health system – clinically, in program development and delivery, academia and in policy –I am now very pleased to be leading the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, or CATSINaM since 2013.

I am proud to be an advocate for the unique and powerful roles that Aboriginal and Torres Strait Islander nurses have in the health system and their communities, as agents of change.

I like to begin my speeches by acknowledging May Yarrowick, who trained as an obstetric nurse in Sydney in 1903. She may well be our first Indigenous nurse qualified in Western nursing.

Let’s take a few moments to reflect upon the challenges that May must have overcome to train and work as a nurse in those times. Remember, this was just a few years after the new federation of Australia passed the Immigration Restriction Act of 1901.

This legislation enshrined the White Australia policy, embedding dominant culture worldviews and priorities into the very birth of the federation, and of course the exclusion of us from Australia’s birth certificate.

Some might say that to this day Australia has not yet grown up – or out of those views.

Too often, the limitations of these dominant culture worldviews stop non-Indigenous people from recognising the incredible strengths of our Aboriginal and Torres Strait Islander peoples and cultures.

Imagine this is now 2037….

Now, I’d like to invite you to cast your minds forward.

Imagine that we have travelled forward in time from May Yarrowick and 1903, all the way to 2037 – 20 years in the future from the time of this conference here in beautiful Cairns.

How old are you in 2037?

I am 62. – I think I look like I belong on the set of the Golden Girls – the Black Betty White. But I am not yet retired. Now that we all are living longer, the retirement age is now 70.

I am happy to still be working. In fact, I am happy to still be alive and in relatively good health.

When I think back to 2017, I remember that I was not at all sure this would be the case. In my early 40s I developed a chronic disease and worried about what it might mean for my future health. But my worries proved unfounded. As I grew older, I remained strong and well.

When I think back over the last few decades, I realise that what helped to keep me feeling good was the strength of my identity, my connection to community and country, and my mentors.

The health literacy that I developed through my nursing career also helped – just one of many ways that developing an Aboriginal and Torres Strait Islander health workforce helps to improve the health of our people.

At 62, I must admit that I am feeling pretty good about myself. My life has had – and continues to have – purpose and meaning, thanks to my passion for improving the health of my people.

So much of my work has been about re-writing national narratives that were once so detrimental to our well-being but are now a source of pride and strength in our identities as members of the world’s oldest living cultures.

One of the reasons I’m so happy is that I am now watching my grandchildren thrive.

I am seeing that their experiences at school and university are so different from my days , and even from those of my children – their parents.

My grandchildren are reading histories and textbooks that have been written by Aboriginal and Torres Strait Islander people.

My grannies are learning from Indigenous teachers and lecturers and television presenters. And they are proud and strong in their identities because of how and what they are learning.

It is such a far cry from when I was at school and university. Then our romanticised and exotic histories were being told by non-Indigenous people, who too often saw us through the overlapping lenses of deficit, unconscious bias and racism.

goodes pmMy grandchildren are learning about the tremendous achievements of our first Indigenous Prime Minister, Mr Adam Goodes.

From their classrooms, they scan in to hear the discussions from the First Nations Parliament.

Self-determination is not an aspiration or even a dream for my great grandchildren. It is their daily reality.

They grow up conscious of whose country they are on

In school, they learn about our many Indigenous health heroes — about people like Professor Tom Calma and Aunty Pat Anderson, & Aunty Gracelyn Smallwood…….

It is not only my grandchildren who are learning about the strengths and proud history of Aboriginal and Torres Strait Islander peoples  – so are their non-Indigenous classmates.

Together, they are learning a shared, true history of this place we call Australia.

My grandchildren and their non-Indigenous friends share in learning local language and they learn together about the importance of respecting and caring for country. They grow up knowing about whose country they were born on – because this is written on their birth certificates and is part of their identities from the day they are born.

slide signpostsThey grow up knowing to always be conscious of whose country they are on – the signs, GPS reminders and names on our maps and roads also remind them of this.

Thanks to the many outcomes of the Truth and Reconciliation Commission, when they go on fun school excursions, they visit fun exhibitions that are informed by our Indigenous knowledges and cultures.

They visit memorials that honour our First Nations people, including our brave Warriors and protectors of country such as Pemulway.

When they go on school excursions, the signage on the streets and highways is not only in English, but also honours the language and naming of the local First Nations peoples.

They grow up with intergenerational hope, not trauma

My grandchildren are growing up in a society that values them and their heritage. They are growing up with intergenerational hope, rather than intergenerational trauma.

They are relative strangers to the experiences of racism that were part of the daily experience of their ancestors over so many generations — including for me, my parents and my children.

The health professionals of the future are learning, from their earliest days, when they first set step into early childhood learning and development centres, about cultural safety. Not that they call it that any more.

Cultural safety has become so embedded into all systems that it has become the norm – rather than something exceptional that people have to learn when they start training to be a nurse or a doctor.

In 2037, cultural safety doesn’t begin in the health system; it begins in our homes and schools. It is evident in our private conversations, and our public debate and discourse.

In 2037, there is no longer a disconnect between public and political discourse – and the language used in the education and training of health professionals.

Politicians of ALL persuasions now understand – just as well as do ALL health professionals – that racism is an attack on people’s health and well-being, and our capacity to live productive, self-determining lives.

slide health careIn 2037, cultural safety has become a societal norm. The cultures, knowledges and practices of Aboriginal and Torres Strait Islander people are central to the national narrative; they are valued and respected.

We have fixed the “racism problem”. Embedding cultural safety into all aspects of society has helped us to transform Eurocentric systems and worldviews.

In 2037, I no longer feel the need to put on my heavy “armour” when I venture outside of my home. It’s a far cry from 20 years ago, when this armour was part of my defence system against the everyday insults of unconscious bias born of racism. Experiences such as deflecting or swallowing hard when I hear:

  • ‘You’ve done well for yourself’
  • ‘Aboriginal people get so much given to them’
  • ‘You’re too pretty to be Aboriginal’
  • ‘Yes, but you’re not like the rest of them, you’re different’
  • or ‘You’re not a real Aboriginal, you’re a half caste’
  • being asked to see my receipt at Woolworths self-serve because ‘they’ve had problems with my sort of people’.

In 2037, I know that when non-Indigenous people see me in the street or at work, their first reaction will not be of prejudice or fear, but of gratitude and pride.

This reflects their understanding of the profound value that Aboriginal and Torres Strait Islander peoples and cultures bring to Australian society.

We have closed the gap in health outcomes

In 2037, when my grandchildren get sick or need to go to the hospital, I no longer even think to worry about whether their care and treatment will be respectful.

No longer do my people leave seeing a doctor or visiting a hospital to the last possible moment because of the fear of being humiliated or traumatised.

The real-time reporting of national safety and quality healthcare data shows that cultural safety is now so embedded across all health systems that Aboriginal and Torres Strait Islander patients are as likely as any other Australians to have proper access to respectful and appropriate care.

The Health Barometer – which was established some years ago to measure our health outcomes, race relations and the cultural safety of health services, programs and policies – has become redundant.

The dual governance boards which Local Area Health Networks established to eradicate racism at the organisational and direct service delivery level are also no longer needed.

There is no longer a gap between the safety and quality of healthcare provided to Aboriginal and Torres Strat Islander people and that provided to other Australians. Our health status is now comparable with other Australians.

The health sector has long ago acknowledged its role in colonisation and such traumatic practices as removal of children and the medical incarceration of Aboriginal and Torres Strait Islander people. Nursing and midwifery now learn this history at the same time as learning about our founders, for example Florence Nightingale.

Health professions and systems have apologised and provided reparation and justice for harmful practices.

Over the past 20 years the sector learnt how to be part of healing, rather than causing harm.

The persistence, hard work and brilliance of our Indigenous health leaders paved the way for a sea change that became evident around the time this century celebrated its 21st birthday.

Climate change prompted a global sea change

I must admit that things were looking pretty grim in the years leading up to 2021. We were still dealing with the aftermath of President Trump, fake news, climate deniers, and the rise of nationalistic, xenophobic movements.

 But as the impacts of climate change started to hit – earlier and harder than expected – there was a profound sea change around the world.

People realised the limitations of the usual Western ways of doing business. Globally, Indigenous knowledges were not only legitimised, but valued and centred in responses to such complex problems as climate change; social and economic inequality; and the protection and management of land and water resources.

As new social and economic structures emerged in response to these challenges and in response to what was then called the Fourth Industrial Revolution, the voices of Indigenous peoples were heard – not only in Australia but also globally.

Our ways of doing business – informed by practices of respect, reciprocity, caring for country, and relationship-based ways of working – are now centred.

Power no longer rested in self-interested hierarchies but became de-centralised. People and organisations were valued for what they could do for the well-being of the community and the planet.

Just imagine what a wonderful difference this has made for rural and remote people and communities!

At the same time as these wider shifts were occurring in society, some fundamental shifts were occurring in health systems.

The health system changed its way of doing business

slide health planIt wasn’t just that the Aboriginal and Torres Strait Islander health plan was fully resourced and implemented – and that this became remembered as one of the landmark achievements of Minister Ken Wyatt, along with establishment of the National Aboriginal and Torres Strait Islander Health Authority.

It wasn’t just that the Rural Health Commissioner’s role was reformed – after some sustained, behind-the-scenes lobbying – to ensure that the Commissioner had a more wide-ranging and meaningful remit.

It wasn’t just that in the wake of the abolition of the Indigenous Advancement Strategy, the Goodes Government set up a Productivity Commission for Indigenous Health. This quarantined, money so that we were able to self-determine the way we invested in our health. And what a difference that made!

It wasn’t just that insurance laws were changed and health systems were reformed to enable women, both Aboriginal and Non- Indigenous women, to birth on country.

It wasn’t any one of these changes alone that led to us closing the gap in life expectancy and health outcomes – years earlier than we had hoped for in our wildest dreams.

It was these things, but it was more than this.

When I look back now, it seems incredible that most of our health dollars and efforts were once spent on centralised, institutional systems of care that contributed relatively little to health outcomes for the large investment they incurred.

It now seems unbelievable that we once invested so little effort and money into providing the conditions that empowered people and their families and communities to have to healthy, contributing lives.

Such a fundamental shift occurred. As Indigenous knowledges and practices were centred in wider systems, so too did the health system change its way of doing business.

.The mainstream health system learnt from the successes of the Aboriginal community controlled health sector. The mainstream re-oriented itself around our ways of doing business – to focus on primary health care, communities, prevention, social justice, and the social and cultural determinants of health.

Health services moved towards providing long-term contracts and seamless services addressing peoples’ needs for inclusion, housing, transport and integrated care.

For our members at CATSINaM, the changes have brought profound transformations to the way they work and how they are valued.

 Our members now work at their full scope of practice. They are involved in diagnosing and managing dental caries, for example, while dentists are incorporating population health strategies into their daily work. Their work has been funded for many years now by ….the sugar tax (dare I say this in Queensland?).

It is so thrilling too to see that the mainstream politic has learnt from the ingenuity of Aboriginal and Torres Strait Islander peoples. Creativity and innovation are not only valued — but properly funded and rewarded.

After its unpromising early years, visionary leadership transformed the NBN to provide equitable access to connectivity right across the country.

Aboriginal and Torres Strait Islander people capitalised on this opportunity, supporting our creativity, entrepreneurialism and innovation. We used the NBN to drive innovation in healthcare and health promotion, as well as to contribute to a better future for all.

We are all making history right now

twitter historyAs I stand before you in 2037, I am not only happy, but I am proud.

One of the highlights of my career has been working to use the virtual world  – cyberspace – to embed cultural safety, not only into the training and education of all who work in the health system – but also into wider societal systems. Along with my newly released cookbook, written in conjunction with the CWA of course.

As we contemplate this potential future together now from our present reality, in 2017, let us remember that history is not something that happens in the past.

It is happening right now. We are all making history right now.

Over the next few years, as we move to embedding cultural safety into our systems and services, supported by the forthcoming Version 2 of the National Safety and Quality Health Service Standards and CATSINaM’s current campaign to have Cultural Safety embedded into our Health Practitioners legislation, let us ensure that this brings meaningful improvement to rural and remote health services.

Let us remember that cultural safety is a philosophy of practice that is about how a health professional does something, not simply what they do. Its focus is on systemic and structural issues and on the social determinants of health.

Cultural safety is as important to quality care as clinical safety. It includes regard for the physical, mental, social, spiritual and cultural components of the patient and the community.

Cultural safety represents a key philosophical shift from providing care regardless of difference, to care that takes account of peoples’ unique needs – and to be regardful of difference.

For Aboriginal and Torres Strait Islander health, cultural safety provides a decolonising model of practice based on dialogue, communication, power sharing and negotiation, and the acknowledgment of white privilege.

These actions are a means to challenge racism at personal and institutional levels, and to establish trust in health care encounters.

Culturally safe and respectful practice therefore is not about learning about Aboriginal and Torres Strait Islander peoples – in fact you can never know this.

Cultural safety requires having knowledge of how one’s own culture, values, attitudes, assumptions and beliefs – influence interactions with patients or clients, their families and the community. Being aware of our racial orator.

As we contemplate a culturally safe future from our current vantage point, let us reflect upon how each and every one of us can contribute to making this future that I’ve shared with you today a reality.

I’d like to conclude this presentation by inviting you to journey with me into the future. I ask each and every one of you to think deeply about how you might contribute to creating this future.

How can YOU help to make history?

Here are some suggestions:

  • Embed cultural safety in your organisation’s strategic plan, and Reconciliation Action Plan.
  • Make anti-racism practice part of your everyday – whether you are at home or at work – and whether anyone is looking or not. Enact zero tolerance for racism.
  • Ensure your governance structures reflect the communities who you are serving. Privilege the voices and the wisdom of Aboriginal and Torres Strait Islander people and organisations.
  • Inform yourself about 18C and Constitutional Recognition.
  • Inform yourself about climate change and the actions you can take – and try to put aside non-Indigenous lenses when doing this. Learn from us about caring for country.
  • Practise trust, respect and reciprocity. Build and value your relationships with us.

In 2037, let us look back on this conference – and this moment – as a time when we stood together, determined to make history and to create a better future.

Because today is tomorrow’s history – be brave.

Thank you.