“A significant number of Indigenous Australian health outcomes are on track to be achieved within four years, an annual Report Card has revealed.
The annual Report Card on the Implementation Plan for The National Aboriginal and Torres Strait Islander Health Plan 2013 to 2023, shows 12 of the 20 goals named in the Plan are on track to be achieved by 2023.
The immunisation target for five-year-old children has been exceeded, with 97 per cent of Indigenous five-year-olds fully immunised, compared to 95 per cent of other children.
All three goals in the maternal health and parenting domain, plus the target for immunisation of two-year-olds, are on track to be achieved by 2023, while all goals related to smoking are expected to be accomplished by the Plan’s completion.
The IHRF is the first national research program led by Indigenous people at all levels, and conducted with close engagement with Indigenous communities,“We have set other clear goals to end avoidable Indigenous blindness by 2025, end avoidable Indigenous deafness, and eliminate rheumatic heart disease over the course of this decade.
These are top priorities within the Morrison Government’s new $160 million, 10-year Indigenous Health Research Fund (IHRF), funded through the Medical Research Future Fund.”
Minister for Health, Greg Hunt, thanked the members of the Implementation Plan Advisory Group, the National Health Leadership Forum and other Aboriginal and Torres Strait Islander leaders, communities and stakeholders, for their involvement in the development of the Report Card.
The Report Card outlines the progress made to date against the Implementation Plan, with improvements across a range of health and social outcomes for Aboriginal and Torres Strait Islander peoples. Some key achievements include:
all three goals in the maternal health and parenting domain are on track to be achieved by 2023;
the 88 percent immunisation target for Aboriginal and Torres Strait Islander 1-year-olds is on track to be met by 2023;
as at 31 December 2018 nationally, 97 per cent of Aboriginal and Torres Strait Islander children aged 5 years were fully immunised, compared with 95 per cent of other children; and
all goals relating to smoking are on track to be achieved by 2023, and this is expected to have an impact on the burden of disease over time.
The Report Card acknowledges that while many health outcomes are improving for Aboriginal and Torres Strait Islander peoples, there is more work needed to close the gap in health inequality.
The Department of Health would like to thank members of the Implementation Plan Advisory Group for their ongoing expertise and contributions to finalising the Report Card, as well as guiding progress towards the next Implementation Plan.
Minister for Indigenous Australians, Ken Wyatt, welcomed the announcement, saying the progress was a result of “strong collaboration between the Government and Australia’s Indigenous community.”
“Our focus is on practical outcomes and empowering local communities to have their say when it comes to the decision-making of Government,” Minister Wyatt said.
“That’s why we’re working with Indigenous communities and governments throughout Australia to improve health outcomes and help close the gap through co-design.”
The Morrison Government is committed to improving the eight goals currently unmeasurable or behind predicted figures.
Over four years from 2019-20, the Government will invest $4.1 billion in dedicated health programs for Indigenous Australians.
These investments are only possible because of our strong economic management
In 2017–18, Indigenous primary health services were delivered from 383 sites (Table 3). Most sites provided clinical services such as the diagnosis and treatment of chronic illnesses (88%), mental health and counselling services (88%), maternal and child health care (86%), and antenatal care (78%). Around two-thirds provided tobacco programs (69%) and substance-use and drug and alcohol programs (66%).
Most organisations provided access to a doctor (86%) and just over half (54%) delivered a wide range of services, including all of the following during usual opening hours: the diagnosis and treatment of illness and disease; antenatal care; maternal and child health care; social and emotional wellbeing/counselling services; substance use programs; and on‑site or off-site access to specialist, allied health and dental care services.
Most organisations (95%) also provided group activities as part of their health promotion and prevention work. For example, in 2017–18, these organisations provided around:
8,400 physical activity/healthy weight sessions
3,700 living skills sessions
4,600 chronic disease client support sessions
4,100 tobacco-use treatment and prevention sessions.
In addition to the services they provide, organisations were asked to report on service gaps and challenges they faced and could list up to 5 of each from predefined lists. In 2017–18, around two-thirds of organisations (68%) reported mental health/social and emotional health and wellbeing services as a gap faced by the community they served.
This was followed by youth services (54%). Over two-thirds of organisations (71%) reported the recruitment, training and support of Aboriginal and Torres Strait Islander staff as a challenge in delivering quality health services.
This is the tenth national report on organisations funded by the Australian Government to provide health services to Aboriginal and Torres Strait Islander people.
Indigenous primary health services
Primary health services play a critical role in helping to improve health outcomes for Aboriginal and Torres Strait Islander people. Indigenous Australians may access mainstream or Indigenous primary health services funded by the Australian and state and territory governments.
Information on organisations funded by the Australian Government under its Indigenous Australians’ health programme (IAHP) is available through two data collections: the Online Services Report (OSR) and the national Key Performance Indicators (nKPIs). Most of the organisations funded under the IAHP contribute to both collections (Table 1).
The OSR collects information on the services organisations provide, client numbers, client contacts, episodes of care and staffing levels. Contextual information about each organisation is also collected. The nKPIs collect information on a set of process of care and health outcome indicators for Indigenous Australians.
This tenth national OSR report presents information on organisations funded by the Australian Government to provide primary health services to Aboriginal and Torres Strait Islander people. It includes a profile of these organisations and information on the services they provide, client numbers, client contacts, episodes of care and staffing levels. Interactive data visualisations using OSR data for 5 reporting periods, from 2013–14 to 2017–18, are presented for the first time.
Key messages
A wide range of primary health services are provided to Aboriginal and Torres Strait Islander people. In 2017–18:
198 organisations provided primary health services to around 483,000 clients, most of whom were Aboriginal and Torres Strait Islander (81%).
These organisations provided around 3.6 million episodes of care, with nearly 3.1 million (85%) delivered by Aboriginal Community Controlled Health Services (ACCHSs).
More than two-thirds of organisations (71%) were ACCHSs. The rest included government-run organisations and other non-government-run organisations.
Nearly half of organisations (45%) provided services in Remoteand Very remote
Services were delivered from 383 sites across Australia. Most sites provided the diagnosis and treatment of chronic illnesses (88%), social and emotional wellbeing services (88%), maternal and child health care (86%), and antenatal care (78%). Around two-thirds provided tobacco programs (69%) and substance-use and drug and alcohol programs (66%).
Organisations made on average nearly 13 contacts per client
In 2017–18, organisations providing Indigenous primary health services made around 6.1 million client contacts, an average of nearly 13 contacts per client (Table 2). Over half of all client contacts (58%) were made by nurses and midwives (1.8 million contacts) and doctors (1.7 million contacts). Contacts by nurses and midwives represented half (49%) of all client contacts in Very remote areas compared with 29% overall.
At 30 June 2018, organisations providing Indigenous primary health services employed nearly 8,000 FTE staff and over half of these (54%) were Aboriginal or Torres Strait Islander. These organisations were assisted by around 270 visiting staff not paid for by the organisations themselves, making a total workforce of around 8,200 FTE staff.
Nurses and midwives were the most common type of health worker (14% of employed staff), followed by Aboriginal and Torres Strait Islander health workers and practitioners (13%) and doctors (7%). Nurses and midwives represented a higher proportion of employed staff in Very remote areas (22%).
Social and emotional health and wellbeing services are the most commonly reported service gap
Organisations can report up to 5 service gaps faced by the community they serve from a predefined list of gaps. Since this question was introduced in 2012–13, the most commonly reported gap has been for mental health and social and emotional health and wellbeing services. In 2017–18, this was reported as a gap by 68% of organisations.
NACCHO Aboriginal Health New AIHW release: Tracking the progress 9 of 20 goal against the Implementation Plan goals for the Aboriginal and Torres Strait Islander Health Plan 2013–2023
In October 2015, the Australian Government released the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023.
The Implementation Plan outlines the actions to be taken by the Australian Government, the Aboriginal community controlled health sector, and other key stakeholders to give effect to the vision, principles, priorities, and strategies of the National Aboriginal and Torres Strait Islander Health Plan 2013–2023.
The Implementation Plan has set goals to be achieved by 2023 for 20 indicators.
These goals were developed to complement the existing COAG Closing the Gap targets, and focus on prevention and early intervention across the life course.
Of the 15 goals currently able to be assessed, 12 are on track
This July 2019 update provides new data for 9 of the 20 goals, that is, those relating to antenatal care, smoking during pregnancy, childhood immunisation and diabetes checks and tests.
For these 9 goals, 7 are on track, and 2 are not on track. New data for the remaining 11 goals is not yet available, with ‘on track’ status for 2 of these still not able to be assessed.
This indicator reports on the age-standardised proportion of Indigenous women who smoked during pregnancy. The goal for this indicator is 37% by 2023.
Why is it important?
Many lifestyle factors contribute to, and can have adverse effects on, the health and wellbeing of a woman and her baby during pregnancy, birth and beyond. Smoking tobacco increases the risk of complications such as miscarriage, ectopic pregnancy, placental abruption and gestational diabetes and is associated with low birthweight, foetal growth restriction, pre-term birth, congenital anomalies and perinatal death.
What data are available?
Data for this indicator were sourced from the National Perinatal Data Collection (NPDC). Perinatal data are collected for each birth in each state and territory, most commonly by midwives.
What do the data show?
Progress towards the goal is on track, with the age-standardised rate in 2016 (42.8%) similar to the trajectory point required to meet the goal (43.4%).
Based on age-standardised rates, the proportion of Indigenous women smoking during pregnancy decreased between 2009 and 2012 (from 50% to 47%). This proportion was slightly higher in 2013 (48%), but lower again in 2014 and 2015 (both 45%) and lower again in 2016 (43%).
In 2016, 44% of Indigenous women reported smoking during pregnancy.
Based on age-standardised rates, in 2016:
the smoking rate among Indigenous women was highest in Very remote areas (53%) and lowest in Major cities (38%)
Indigenous women were substantially more likely than non-Indigenous women to report smoking during pregnancy—43% compared with 12%.
Included in this NACCHO Aboriginal Health News Alert
All issues 11 included in Communique highlighting ACCHO health
Health Ministers approve Australia’s National Digital Health Strategy
Transcript Health Minister Hunt Press Conference
” The Federal Minister for Indigenous Health, Ken Wyatt, attended the COAG Health Council discussed the Commonwealth’s current work on Indigenous health priorities.
In particular this included the development of the 2018 iteration of the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013-2023 that will incorporate strategies and actions to address the social determinants and cultural determinants of health.
Ministers also considered progress on other key Indigenous health issues including building workforce capability, cultural safety and environmental health, where jurisdictions can work together more closely with the Commonwealth to improve outcomes for Aboriginal and Torres Strait Islander peoples.
Ministers acknowledged the importance of collaboration and the need to coordinate activities across governments to support a culturally safe and comprehensive health system.
Ministers also acknowledge the importance of community controlled organisations in advancing Aboriginal and Torres Strait Islander health. ”
1.Development of the next iteration of the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023 COAG Health Council
The federal, state and territory Health Ministers met in Brisbane on August 4 at the COAG Health Council to discuss a range of national health issues.
The meeting was chaired by the Victorian Minister for Health, the Hon Jill Hennessy MP.
Health Ministers welcomed the New South Wales Minister for Mental Health, the Hon Tanya Davies MP, the Victorian Minister for Mental Health, the Hon Martin Foley MP, the ACT Minister for Mental Health Mr Shane Rattenbury and the Minister for Aged Care and Minister for Indigenous Health, the Hon Ken Wyatt AM, MP who participated in a joint discussion with Health Ministers about mental health issues.
Major items discussed by Health Ministers today included:
2.Andrew Forrest and the Eliminate Cancer Initiative
Mr Andrew Forrest joined the meeting to address Health Ministers in his capacity as Chairman of the Minderoo Foundation to discuss the Eliminate Cancer Initiative. The Minderoo Foundation is one of Autralia’s largest and most active philanthropic groups. It has established the Eliminate Cancer Initiatve (the Initiative), a global initiative dedicated to making cancer non-lethal with some of the world’s leading global medicine and anti-cancer leaders.
The Initiative is a united effort to convert cancer into a non-lethal disease through global collaboration of scientific, medical and academic institutes, commercially sustained through the support of the philanthropic, business and government sectors worldwide.
Australia has a critical role to play in this highly ambitious and thoroughly worthwhile goal.
3.Family violence and primary care
Today, Health Ministers discussed the significant health impacts on those people experiencing family violence.
Health Ministers acknowledged that health-care providers, particularly those in a primary care setting, are in a unique position to create a safe and confidential environment to enable the disclosure of violence, while offering appropriate support and referrals to other practitioners and services.
Recognising the importance of national leadership in this area, Ministers agreed to develop a plan to address barriers to primary care practitioners identifying and responding to patients experiencing family violence.
Ministers also agreed to work with the Royal Australian College of General Practitioners to develop and implement a national training package.
Further advice will be sought from Primary Health Networks on existing family violence services, including Commonwealth, State and NGO service providers in their regions, with a view to developing an improved whole-of-system responses to the complex needs of clients who disclose family violence
4.Fifth National Mental Health and Suicide Prevention Plan
Health Ministers endorsed the Fifth National Mental Health and Suicide Prevention Plan 2017-2022 and its Implementation Plan.
The Fifth Plan is focused on improvements across eight targeted priority areas:
1. Achieving integrated regional planning and service delivery
2. Effective suicide prevention
3. Coordinated treatment and supports for people with severe and complex mental illness
4. Improving Aboriginal and Torres Strait Islander mental health and suicide prevention
5. Improving the physical health of people living with mental illness and reducing early mortality
6. Reducing stigma and discrimination
7. Making safety and quality central to mental health service delivery
8. Ensuring that the enablers of effective system performance and system improvement are in place
The Fifth Plan also responds to calls for a national approach to address suicide prevention and will be used to guide other sectors and to support health agencies to interact with other portfolios to drive action in this priority area.
Ongoing collaboration and engagement across the sector and with consumers and carers is required to successfully implement the Fifth Plan and achieve meaningful reform to improve the lives of people living with mental illness including the needs of children and young people.
Health Ministers also agreed that mental health workforce issues would be considered by the Australian Health Ministers’ Advisory Council.
5.The National Psychosocial Supports Program
Health Ministers agreed to establish a time-limited working group to progress the Commonwealth’s National Psychosocial Supports program. This will have the objective of developing bilateral agreements to support access to essential psychosocial supports for persons with severe mental illness resulting in psychosocial disability who are not eligible for the NDIS.
Those bilateral agreements will take into account existing funding being allocated for this purpose by states and territories.
6.Strengthened penalties and prohibition orders under the Health Practitioner Regulation National Law
Health Ministers agreed to proceed with amendments to the Health Practitioner Regulation National Law (the National Law) to strengthen penalties for offences committed by people who hold themselves out to be a registered health practitioner, including those who use reserved professional titles or carry out restricted practices when not registered.
Ministers also agreed to proceed with an amendment to introduce a custodial sentence with a maximum term of up to three years for these offences.
These important reforms will be fast tracked to strengthen public protection under the National Law. Preparation will now commence on a draft amendment bill to be brought forward to Ministers for approval, with a view to this being introduced to the Queensland Parliament in 2018. The Western Australian Parliament is also expected to consider legislative changes to the Western Australian National Law.
7.Amendment to mandatory reporting provisions for treating health practitioner
Health Ministers agree that protecting the public from harm is of paramount importance as is supporting practitioners to seek health and in particular mental health treatment as soon as possible.
Health Ministers agreed that doctors should be able to seek treatment for health issues with confidentiality whilst also preserving the requirement for patient safety.
A nationally consistent approach to mandatory reporting provisions will provide confidence to health practitioners that they can feel able to seek treatment for their own health conditions anywhere in Australia.
Agree for AHMAC to recommend a nationally consistent approach to mandatory reporting, following discussion paper and consultation with consumer and practitioner groups, with a proposal to be considered by COAG Health Council at their November 2017 meeting, to allow the amendment to be progressed as part of Tranche 1A package of amendments and related guidelines.
8.National Digital Health Strategy and Australian Digital Health Agency Forward Work Plan 2018–2022
Health Ministers approved the National Digital Health Strategy and the Australian Digital Health Agency Work Plan for 2018-2022.
The Strategy has identified the priority areas that form the basis of Australia’s vision for digital health.
This Strategy will build on Australia’s existing leadership in digital health care and support consumers and clinicians to put the consumer at the centre of their health care and provide choice, control and transparency.
Expanding the public reporting of patient safety and quality measures
Health Ministers supported Queensland and other interested jurisdictions to collaboratively identify options in relation to aligning patient safety and quality reporting standards across public and private hospitals nationally.
Ministers agreed that the Australian Commission on Safety and Quality in Health Care (ACSQHC) would undertake work with other interested jurisdictions to identify options in relation to aligning public reporting standards of quality healthcare and patient safety across public and private hospitals nationally.
The work be incorporated into the national work being progressed on Australia’s health system performance information and reporting frameworks.
9.National human biomonitoring program
Health Ministers noted that human biomonitoring data can play a key role in identifying chemicals which potentially cause adverse health effects and action that may need to be taken to protect public health.
Health Ministers agreed that a National Human Biomonitoring Program could be beneficial in assisting with the understanding of chemical exposures in the Australian population.
Accordingly, Ministers agreed that the Australian Health Ministers’ Advisory Council will explore this matter in more detail by undertaking a feasibility assessment of a National Human Biomonitoring Program.
Clarification of roles, responsibilities and relationships for national bodies established under the National Health Reform Agreement
States and territories expressed significant concern that the proposed Direction to IHPA will result in the Commonwealth retrospectively not funding activity that has been already delivered by states and territories but not yet funded by the Commonwealth.
States and territories were concerned that this could reduce services to patients going forward as anticipated funding from the Commonwealth will be less than currently expected.
The Commonwealth does not agree with the concerns of the states and territories and will seek independent advice from the Independent Hospital Pricing Authority (IHPA) to ensure hospital service activity for 2015-2016 has been calculated correctly. The Commonwealth committed to work constructively and cooperatively with all jurisdictions to better understand the drivers of increased hospital services in funding agreements.
10.Legitimate and unavoidable costs of providing public hospital services in Western Australia
Health Ministers discussed a paper by Western Australia on legitimate and unavoidable costs of providing public hospital services in Western Australia, particularly in regional and remote areas, and recognised that those matters create a cumulative disadvantage to that state. Health Ministers acknowledged that Western Australia will continue to work with the Commonwealth Government and the Independent Hospital Pricing Authority to resolve those matters.
11.Vaccination
Health Ministers unanimously confirmed the importance of vaccination and rejected campaigns against vaccination.
All Health Ministers expressed their acknowledgement of the outgoing Chair, the Hon Ms Jill Hennessy and welcomed the incoming Chair Ms Meegan Fitzharris MLA from the Australian Capital Territory.
Health Ministers approve Australia’s National Digital Health Strategy
Digital information is the bedrock of high quality healthcare.
The benefits for patients are signicant and compelling: hospital admissions avoided, fewer adverse drug events, reduced duplication of tests, better coordination of care for people with chronic and complex conditions, and better informed treatment decisions. Digital health can help save and improve lives.
To support the uptake of digital health services, the Council of Australian Governments (COAG) Health Council today approved Australia’s National Digital Health Strategy (2018-2022).
In a communique issued after their council meeting in Brisbane August 4 , the Health Ministers noted:
“The Strategy has identified the priority areas that form the basis of Australia’s vision for digital health. It will build on Australia’s existing leadership in digital health care and support consumers and clinicians to put the consumer at the centre of their health care and provide choice, control, and transparency.”
Australian Digital Health Agency (ADHA) CEO Tim Kelsey welcomed COAG approval for the new Strategy.
“Australians are right to be proud of their health services – they are among the best, most accessible, and efficient in the world.
Today we face new health challenges and rapidly rising demand for services. It is imperative that we work together to harness the power of technology and foster innovation to support high quality, sustainable health and care for all, today and into the future,” he said.
The Strategy – Safe, seamless, and secure: evolving health and care to meet the needs of modern Australia – identifies seven key priorities for digital health in Australia including delivery of a My Health Record for every Australian by 2018 – unless they choose not to have one.
More than 5 million Australians already have a My Health Record, which provides potentially lifesaving access to clinical reports of medications, allergies, laboratory tests, and chronic conditions. Patients and consumers can access their My Health Record at any time online or on their mobile phone.
The Strategy will also enable paper-free secure messaging for all clinicians and will set new standards to allow real-time sharing of patient information between hospitals and other care professionals.
Australian Medical Association (AMA) President Dr Michael Gannon has welcomed the Strategy’s focus on safe and secure exchange of clinical information, as it will empower doctors to deliver improved patient care.
“Doctors need access to secure digital records. Having to wade through paperwork and chase individuals and organisations for information is
archaic. The AMA has worked closely with the ADHA on the development of the new strategy and looks forward to close collaboration on its implementation,” Dr Gannon said.
Royal Australian College of General Practitioners (RACGP) President Dr Bastian Seidel said that the RACGP is working closely and collaboratively with the ADHA and other stakeholders to ensure that patients, GPs, and other health professionals have access to the best possible data.
“The Strategy will help facilitate the sharing of high-quality commonly understood information which can be used with confidence by GPs and other health professionals. It will also help ensure this patient information remains confidential and secure and is available whenever and wherever it is needed,” Dr Seidel said.
Pharmacy Guild of Australia National President George Tambassis said that technology would increasingly play an important role in supporting sustainable healthcare delivery.
“The Guild is committed to helping build the digital health capabilities of community pharmacies and advance the efficiency, quality, and delivery of healthcare to improve health outcomes for all Australians.
“We are working with the ADHA to ensure that community pharmacy dispensing and medicine-related services are fully integrated into the My Health Record – and are committed to supporting implementation of the National Digital Health Strategy as a whole,” George Tambassis said.
Pharmaceutical Society of Australia (PSA) President Dr Shane Jackson said that the Strategy would support more effective medicationmanagement, which would improve outcomes for patients and improve the efficiency of health services.
“There is significant potential for pharmacists to use digital health records as a tool to communicate with other health professionals, particularly during transitions of care,” Dr Jackson said.
The Strategy will prioritise development of new digital services to support newborn children, the elderly, and people living with chronic disease. It will also support wider use of telehealth to improve access to services, especially in remote and rural Australia and set standards for better information sharing in medical emergencies – between the ambulance, the hospital, and the GP.
Consumers Health Forum (CHF) Leanne Wells CEO said that the Strategy recognises the importance of empowering Australians to be makers and shapers of the health system rather than just the users and choosers.
“We know that when consumers are activated and supported to better self-manage and coordinate their health and care, we get better patient experience, quality care, and better health outcomes.
“Digital health developments, including My Health Record, are ways in which we can support that to happen. It’s why patients should also be encouraged to take greater control of their health information,” Leanne Wells said.
Medical Software Industry Association (MSIA) President Emma Hossack said that the Strategy distils seven key themes that set expectations at a national level.“The strategy recognises the vital role industry plays in providing the smarts and innovation on top of government infrastructure.
This means improved outcomes, research, and productivity. Industry is excited to work with the ADHA to develop the detailed actions to achieve the vision which could lead to Australia benefitting from one of the strongest health software industries in the world,” Emma Hossack said.
Health Informatics Society of Australia (HISA) CEO Dr Louise Schaper welcomed the Strategy’s focus on workforce development.
“If our complex health system is to realise the benefits from information and technology, and become more sustainable, we need clinical leaders with a sound understanding of digital health,” Dr Schaper said.
The Strategy was developed by all the governments of Australia in close partnership with patients, carers and the clinical professionals who serve them – together with leaders in industry and science.
The Strategy draws on evidence of clinical and economic benefit from many sources within Australia and overseas, and emphasises the priority of patient confidentiality as new digital services are implemented.
The ADHA has established a Cyber Security Centre to ensure Australian healthcare is at the cutting edge of international data security.
The ADHA, which has responsibility for co-ordinating implementation of the Strategy, will now be consulting with partners across the community to develop a Framework for Action. The framework will be published later this year and will detail implementation plans for the Strategy.
The National Digital Health Strategy Safe, seamless and secure: evolving health and care to meet the needs of modern Australia is available on
Topics: COAG Health Council outcomes; The Fifth National Mental Health and Suicide Prevention Plan; support for doctors and nurses mental health; hospital funding; same-sex marriage
GREG HUNT:
Today was a huge breakthrough in terms of mental health. The Fifth National Mental Health Plan was approved by the states.
What this is about is enormous progress on suicide prevention. It has actually become the Fifth National Mental Health and Suicide Prevention Plan, so a real focus on suicide prevention.
In particular, the focus on what happens when people are discharged from hospital, the group in Australia that are most likely to take their own lives.
We actually know not just the group, but the very individuals who are most at risk. That’s an enormous step.
The second thing here is, as part of that plan, a focus on eating disorders, and it is a still-hidden issue. In 2017, the hidden issue of eating disorders, of anorexia and bulimia, and the prevalence and the danger of it is still dramatically understated in Australia.
The reality is that this is a silent killer and particularly women can be caught up for years and years, and so there’s a mutual determination, a universal determination to progress on eating disorders, and that will now be a central part of the Fifth National Mental Health and Suicide Prevention Plan.
And also, as part of that, we’ve included, at the Commonwealth’s request today, a real focus on early intervention services for young people under 16. Pat McGorry has referred to it as CATs for Kids, meaning Crisis Assessment Teams, and the opportunity.
And this is a really important step because, for many families, when they have a crisis, there’s nowhere to turn. This is a way through. So those are all enormous steps forward.
The other mental health area where we’ve made big, big progress is on allowing doctors to seek routine mental health treatment.
There’s an agreement by all of the states and territories to work with the Commonwealth on giving doctors a pathway so as they can seek routine mental health treatment without being reported to the professional bodies.
JOURNALIST:
What has led to the increased focus on eating disorders? Has there been an uptick in the number of suicides resulting from that, or has there been an uptick in the number of cases?
GREG HUNT:
No, this has been silently moving along. It’s a personal focus. There are those that I have known, and then when we looked the numbers shortly after coming in, and dealt with organisations such as the Butterfly Foundation, they explained that it’s been a high level issue with the worst rate of loss of life amongst any mental health condition.
And so that’s a combination both of suicide, but also of loss of life due to physical collapse. And so it’s what I would regard as a personal priority from my own experience with others, but then the advocacy of groups like Butterfly Foundation has finally landed. It should’ve happened earlier, but it’s happening on our watch now.
JOURNALIST:
That would be my next question, is that I’m sure advocacy groups will say this is great that it’s happened, but it’s taken the Government so long. Why is it that you’re focussing on it now as opposed to…?
GREG HUNT:
I guess, I’ve only just become Minister. So from day one, this is one of the things I’ve wanted to do, and I’m really, personally, deeply pleased that we’ve made this enormous progress.
So I would say this, I can’t speak for the past, it is overdue, but on our watch collectively we’ve taken a huge step forward today.
Then the last thing is I’ve seen some reports that Queensland and Victoria may have been upset that some of their statistical anomalies were referred to what’s called IHPA (Independent Hospital Pricing Authority).
The reason why is that some of their figures simply didn’t pass the pub test.
The independent authority will assess them, but when you have 4000 per cent growth in one year in some services, 3300 per cent growth in some years in other services, then it would be negligent and irresponsible not to review them.
It may be the case that there was a more than 40-fold increase in some services, but the only sensible thing for the Commonwealth to do is to review it.
But our funding goes up each year every year at a faster rate than the states’ funding, and it’s gone up by $7.7 billion dollars since the current health agreement with the states was struck.
JOURNALIST:
Is that, sorry, relating to private health insurance, or is that something separate?
GREG HUNT:
No, that’s just in relation to, a couple of the states lodged claims for massive growth in individual items.
JOURNALIST:
Thank you. So was there a directive given today regarding private health policies to the states? Was that something that was discussed or something that …?
GREG HUNT:
Our paper was noted, and the states will respond. So we’ve invited the states to respond, they’ll respond individually.
JOURNALIST:
And regarding that mental health plan, besides their new focus on eating disorders, how is it different from previous mental health plans?
GREG HUNT:
So, a much greater focus on suicide prevention, a much greater focus on eating disorders, and a much greater focus on care for young children under 16.
JOURNALIST:
Is that something that you can give more specific details about? You’re saying there’s a much greater focus, but is there any specific information about what that would mean?
GREG HUNT:
As part of the good faith, the Commonwealth, I’ve written to the head of what’s called the Medical Benefits Schedule Review, so the Medicare item review, Professor Bruce Robinson and asked him and their team to consider, for the first time, specific additional treatment, an additional treatment item and what would be appropriate for eating disorders.
” Health risk factors like smoking, excessive drinking, illicit drug use, lack of physical activity, inadequate fruit and vegetable intake and overweight have powerful influences on health, and there are frequently clear inter-regional differences between the prevalence of these.
While it can be argued that there is some degree of personal choice involved in whether individuals have a poor health risk profile, there is clear evidence that external factors such as environment, opportunity, and community culture each have very strong influences.
For example, access to affordable healthy food can often be poor in smaller communities and this, coupled with lower incomes in these areas, adversely affects the quality of peoples’ diets, the prevalence of overweight, and consequently the prevalence of chronic disease.”
From the National Rural Health Alliance ResearchView HERE
National data pertaining to personal health risk factors typically comes from the ABS National Health Survey and the AIHW National Drug Strategy Household Survey (NDSHS). Some State and Territory Health Departments run their own health surveys (which cannot be aggregated nationally with each other or with the ABS survey because of the different methodologies and definitions used (think different State rail gauges). Consequently data describing aspects of health in regional and especially remote areas can be thin (ie with imprecise estimates in some or all areas).
Example 1
Table 14: Fruit and vegetable consumption, Aboriginal and Torres Strait Islander people 15+ years, 2012-13
Roughly 60% of Aboriginal and Torres Strait Islander Australians 15+ in Major cities and regional/rural areas have inadequate fruit intake, closer to 50% in remote areas (compared with around 50% of all Australians 18+ in major cities and regional/rural areas).
Roughly 95% of Aboriginal and Torres Strait Islander Australians 15+ in Major cities and regional/rural areas have inadequate vegetable intake, perhaps higher (98%) in Very remote areas (compared with around 90%-94% of all Australians 18+ in major cities and regional/rural areas).
Example 2
NACCHO provided graphic
Table 16 Below : Overweight and Obesity, Aboriginal and Torres Strait Islander people 15+ years, 2012-13
Aboriginal and Torres Strait Islander people in rural/regional and Remote areas (29%-33%) were a little more likely to be overweight than those in Major cities (28%), with those in Very Remote areas (26%) least likely to be overweight.
Aboriginal and Torres Strait Islander people in Inner regional areas (41%) were more likely to be obese than those in Major cities (38%), but those in Outer regional (36%) and remote areas (~33%) were less likely to be obese.
Overall, Aboriginal and Torres Strait Islander people in Inner Regional areas were most likely to be overweight/obese (70%), those in Major cities, Outer Regional and Remote areas were less likely to be overweight/obese (~66%), while those in Very Remote areas were the least likely to be overweight/obese (59% )
At the time of writing, the most recent National Health Survey was conducted in 2014-15[1], while the most recent AIHW NDSHS[2] was conducted in 2016, with most recently available results from the 2013 NDSHS. The most recent ABS Australian Aboriginal and Torres Strait Islander Health Survey[3] was conducted in 2012-13.
Some organisations (eg the Public Health Information Development Unit (PHIDU)) have calculated modelled estimates for small areas (eg SLA’s and PHN’s), where the prevalence of some risk factors has been predicted based on the age, sex and socioeconomic profile of the population living there.
Some sites (eg ABS) present risk factor data as crude rates, other sites (eg PHIDU) present risk factor data as age-standardised rates. The advantage of the age-standardised rates is that the effect of age is largely removed from inter-population comparisons.
For example, older populations (eg those in rural/regional areas) would be expected to have higher average blood pressure than younger (eg Major cities) populations even though the underlying age-specific rates happened to be identical in both populations (because older people tend to have higher blood pressure than younger people).
While crude rates for the older population will be higher, the age-standardised rates in such a comparison would be the same – indicating a higher rate that is entirely explainable by the older age of one of the populations.
Both crude and age standardised rates are useful in understanding the health of rural and remote populations.
Compared with Major cities (13%), the prevalence of daily smoking by people 18 years and older in Inner regional (17%) and Outer regional/Remote areas (21%) is higher.
The NDSH survey reflects these trends albeit with a slightly different age group (14+) and a different definition of smoking (daily plus less frequently), but the NDSH survey adds detail for remote areas where smoking rates are higher again (around 25% versus around 23% in Outer regional).
In addition, the average number of cigarettes smoked by each smoker is higher in regional/rural areas (~110/week) than in Major cities (86/week), and higher again (126/week) in remote areas.
Table 2: Smoking characteristics by Remoteness, 2013, 2014 and 2014-15
MC
IR
OR
remote
8.8
17.8
19.3
27.8
Proportion of pregnant women who gave birth and smoked at any time during the pregnancy (2013, crude, National Perinatal Data Collection, exposure tables, Table 5.1.2 )
8.5
17.0
18.9
27.5
Proportion of pregnant women who gave birth and smoked in the first 20 weeks of pregnancy (2013, crude, National Perinatal Data Collection) exposure tables, Table 5.2.2)
3.6
3.1
4.1
*9.4
Proportion of dependent children (aged 0–14) who live in a household with a daily smoker who smokes inside the home (2013, crude, NDSHS exposure tables, Table 6.3)
2.5
2.0
2.7
*2.9
Proportion of adults aged 18 or older who live in a household with a daily smoker who smokes inside the home (2013, crude, NDSHS, exposure tables, Table 7.3)
16.2
15.4
14.7
15.5
Average age at which people aged 14–24 first smoked a full cigarette (2013, crude, NDSHS, uptake tables, Table 9.3)
17.8
22.7
17.8
28.3
Proportion of 12–17 year old secondary school students smoking at least a few puffs of a cigarette (2014, crude, Australian Secondary Students Alcohol and Drug Survey 2014, uptake tables, Table 10.3
54.7
61.1
64.9
67.2
Proportion of persons (aged 18 or older) who have smoked a full cigarette (2013, crude, NDSHS, uptake tables, Table 10.8)
2.5
3.4
2.5
3.7
Proportion of secondary school students (aged 12–17) who have smoked more than 100 cigarettes in their lifetime (2014, crude, Australian Secondary Students Alcohol and Drug Survey 2014, transition tables, Table 2.3)
20.2
25.9
44.1
45.2
Proportion of young people (aged 18–24) who have smoked more than 100 cigarettes in their lifetime (2013, crude, NDSHS, transition tables, Table 2.6)
21.3
16.8
19.0
15.5
Quitting: Proportion successfully gave up for more than a month (2013, crude, NDSHS, cessation tables, Table 4.3)
Mean age at which ex-smokers aged 18 or older reported no longer smoking (2013, crude, NDSHS, cessation tables, Table 11.2)
53.1
51.5
46.3
45.0
The proportion of ever smokers aged 18 or older who did not smoke in the last 12 months (2013, crude, NDSHS, cessation tables, Table 12.3)
4.9
6.0
4.8
7.0
Proportion of secondary school students (aged 12–17) who were weekly smokers (2014, crude, Australian Secondary Students Alcohol and Drug Survey 2014, established tables, Table 1.3)
6.9
9.3
6.8
10.4
Proportion of secondary school students (aged 12–17) who were monthly smokers (2014, crude, Australian Secondary Students Alcohol and Drug Survey 2014, established tables, Table 13.3)
13.0
16.7
21.2
18.8
Proportion of adults aged 18 or older who are daily smokers (2014-15, crude, ABS NHS, established tables, Table 3.3)
10.9
7.8
2.9
n.p.
Proportion of smokers aged 18 or older who are occasional smokers (smoke weekly or less than weekly) (2014-15, crude, ABS NHS, established tables, Table 14.3)
40.1
44.7
42.3
52.7
Proportion of Aboriginal and Torres Strait Islander people aged 18 or older who are daily smokers (2012-13, crude, ABS Australian Aboriginal and Torres Strait Islander Health Survey 2012–13, established tables, Table 8i.3)
Women in rural and remote areas were much more likely to smoke during pregnancy, with 28% of women in remote areas smoking during pregnancy, compared with 18-19% in regional/rural areas, and 9% in Major cities.
It is unclear whether exposure to environmental tobacco smoke varies by remoteness.
Young people outside major cities appeared to have their first cigarette at an earlier age (~15 years as opposed to ~16 years in Major cities.
Secondary school students in Inner regional (~23%) and remote (~28%) areas were more likely to have had at least a few puffs of a cigarette than those in major cities (~18%).
While 20% of young people in Major cities had smoked more than 100 cigarettes in their lifetime, 26%, 44% and 45% of young people in Inner regional, Outer regional and remote areas had done so.
People outside Major cities were as likely or slightly more likely to have attempted to quit smoking, but were less likely to be successful (and more likely to be unsuccessful).
A higher proportion of secondary students outside Major cities were weekly or monthly smokers (6%, 5% and 7% in IR, OR and remote areas versus 5% in Major cities weekly, 9%, 7%, and 10% in IR, OR and remote areas versus 7% in Major cities monthly).
Table 3: Current daily smoker, Aboriginal and Torres Strait Islander people 15+ years, by Remoteness, 2012-13
Prevalence of smoking amongst Aboriginal and Torres Strait Islander people 15 years and older is around 35%-40% in Major cities and regional/rural areas, and close to 50% in remote areas. Note that while the pattern is similar in Table 2 and Table 3 above, the figures for 18+ and 15+ year olds are slightly different.
Smoking Trends
Table 4: Comparison of declines in smoking rate estimates across remoteness areas, people 18+, based on ABS NHS surveys, 2001 to 2011-12
Survey year
MC
IR
OR/Rem
Australia
Crude percent daily smokers
2001
21.9
21.9
26.5
22.4
2004-05
19.9
23.0
26.2
21.3
2007-08
17.5
20.1
26.1
18.9
2011-12
14.7
18.3
22.2
16.1
2014-15
13.0
16.7
20.9
14.5
Source: ABS National Health Surveys
From Table 4 above, rates of smoking have clearly declined in Major cities areas, but have been slower to decline in Inner regional and Outer regional/Remote areas. Rates of smoking in rural areas, apparently static last decade, now appear to be declining. Rates in Major cities and Inner regional areas have declined to 0.59 and 0.76 times the 2001 rates in these areas. The 2014-15 rate in Outer regional areas is 0.79 times the 2001 rate.
Figure 1: Daily smokers 18 years and older, 2007-08, 2011-12 and 2014-15, NHS
Note: Smokers include daily, weekly and less frequent smokers.
Figures 1 and 2 above both show clear declines in Major cities and Inner regional areas, but the trend in Outer regional and Remote areas is less clear, with ABS data showing a decline in daily smoking rates for people aged 18+ between 2007-8 and 2014-15, but NDSHS data showing little change in smoking rates for people 14+ between 2007 and 2013.
Alcohol
Table 5: Alcohol risk status, by remoteness, 2013 and 2014-15
The figures in Table 6 are not strictly comparable with those for the total population in Table 5, because Table 6 refers to people who are 15 years and older, while Table 5 refers to people who are 18 years and older.
The percentage of the 15+ ATSI population exceeding 2009 NHMRC Lifetime risk guidelines is around 15-20% with little apparent inter-regional variation, compared with, for the total population 18+, 16% in Major cities, increasing to 23% in Outer regional/remote areas.
The percentage of the 15+ ATSI population exceeding the 2009 single occasion risk guidelines is around 50-60%, and around 40% in Very remote areas, compared with, for the total population 18+, 40-50% in Major cities, rural and regional areas.
Alcohol trends
Table 7: Type of alcohol use and treatment for alcohol, by remoteness area (per 1,000 population)
Notes:
Single occasion risk (monthly): Had more than 4 standard drinks at least once a month
Lifetime risk: On average, had more than 2 standard drinks per day
Very high risk (yearly): Had more than 10 standard drinks at least once a year
Very high risk (monthly): Had more than 10 standard drinks at least once a month
Very high risk (weekly): Had more than 10 standard drinks at least once a week
There is a clear increase in the prevalence of people who drink alcohol in such a way as to increase their single occasion risk (eg from car accident, assault, fall, etc) and their lifetime risk (eg from chronic disease – liver disease, dementia, cancer etc) as remoteness increases.
In 2013, single occasion risk ranged from 25% of people 14 years or older in major cities to 42% of people in remote areas, while lifetime risk increased from 17% in major cities to 35% in remote areas.
In 2013, The prevalence of people who drank more than 10 standard drinks in one sitting at least once per week, increased from just under 3% in Major cities to 7% in remote areas.
In 2013-14, there were just under 70 closed treatment episodes per 1,000 people living in Major cities, increasing to around 80 and 90 per 1,000 population in Inner and Outer regional areas, to 155 per 1,000 people living in remote Australia.
Illicit drug use 2013
Table 8: Illicit drug use, “recent users” 14+, 2013
Note: * indicates large standard error (therefore some degree of uncertainty)
Illicit drug use appears to be higher in Outer regional and remote areas compared with Major cities and Inner regional areas, in large part due to higher rates of cannabis use in these areas, but with apparent lower use of ecstasy and cocaine in regional areas compared with Major cities.
Physical activity
Table 9: Physical inactivity, people 18+, 2014-15
MC
IR
OR/Remote
Percentage of people aged 18+ who undertook no or low exercise in the previous week (crude) (a)
64.3
70.1
72.4
Percentage of people aged 18+ who undertook no or low exercise in the previous week (age standardised) (b)
In 2011-12, adults living in Outer regional/Remote areas took slightly more steps than those living in Major cities or Inner regional areas, while the number of steps taken by children and adolescents in regional/Remote areas was slightly greater compared with those in Major cities.
Table 11: Average time spent on physical activity and sedentary behaviour by persons aged 18+, 2011-12
MC
IR
OR/Remote
Australia
Hours
Physical activity(a)
3.9
3.4
3.9
3.8
Sedentary behaviour (leisure only)(b)
29.3
28.0
27.9
28.9
Sedentary behaviour (leisure and work)(b)
40.2
35.2
36.0
38.8
Notes:
(a) Includes walking for transport/fitness, moderate and vigorous physical activity.
(b) Sedentary is defined as sitting or lying down for activities.
Adults living in Inner regional and Outer regional/Remote areas were about as likely as (or very slightly less likely than) those in Major cities to be sedentary in their leisure time, but appeared to be slightly less likely to be sedentary overall (ie their work involved a greater level of physical activity).
Table 12: Whether children aged 2-17 years met physical and screen-based activity recommendations, 2011-12
MC
IR
OR/Rem
Crude percentage
Met physical activity recommendation on all 7 days(a)(b)
27.5
34.3
34.2
Met screen-based activity recommendation on all 7 days(b)(c)
28.0
29.7
31.0
Met physical activity and screen-based recommendations on all 7 days (a)(b)(c)
9.7
10.9
14.2
Notes:
(a) The physical activity recommendation for children 2–4 years is 180 minutes or more per day, for children 5-17 years it is 60 minutes or more per day. See Physical activity recommendation in Glossary.
(b) In 7 days prior to interview.
(c) The screen-based recommendation for children 2–4 years is no more than 60 minutes per day, for children 5-17 years it is no more than 2 hours per day for entertainment purposes.
Children in rural and regional Australia appeared more likely (34% vs 28%) to meet physical activity recommendations and slightly more likely (30%vs 28%) to meet screen-based activity recommendations than their Major cities counterparts.
Fruit and vegetable consumption
Table 13: Fruit and vegetable consumption, people 18+ years, by remoteness, 2014-15
Roughly 60% of Aboriginal and Torres Strait Islander Australians 15+ in Major cities and regional/rural areas have inadequate fruit intake, closer to 50% in remote areas (compared with around 50% of all Australians 18+ in major cities and regional/rural areas).
Roughly 95% of Aboriginal and Torres Strait Islander Australians 15+ in Major cities and regional/rural areas have inadequate vegetable intake, perhaps higher (98%) in Very remote areas (compared with around 90%-94% of all Australians 18+ in major cities and regional/rural areas).
Overweight and Obesity
Table 15: Overweight and Obesity, people 18+ years, by remoteness, 2014-15
Adults in rural/regional areas are more likely to be overweight or obese than people in Major cities (69% vs 61%).
However, there were inter-regional BMI and gender differences:
Compared with those in Major cities, males in Inner regional and especially Outer-regional areas were less likely to be overweight (41% and 34%, vs 44%) but much more likely to be obese (33% and 38% vs 26%).
Compared with those in Major cities, females in Inner regional and Outer-regional areas were about as likely to be overweight (~29%) but much more likely to be obese (~33% vs 25%).
Table 16: Overweight and Obesity, Aboriginal and Torres Strait Islander people 15+ years, 2012-13
Aboriginal and Torres Strait Islander people in rural/regional and Remote areas (29%-33%) were a little more likely to be overweight than those in Major cities (28%), with those in Very Remote areas (26%) least likely to be overweight.
Aboriginal and Torres Strait Islander people in Inner regional areas (41%) were more likely to be obese than those in Major cities (38%), but those in Outer regional (36%) and remote areas (~33%) were less likely to be obese.
Overall, Aboriginal and Torres Strait Islander people in Inner Regional areas were most likely to be overweight/obese (70%), those in Major cities, Outer Regional and Remote areas were less likely to be overweight/obese (~66%), while those in Very Remote areas were the least likely to be overweight/obese (59%).
These figures compare with 61% – the prevalence of overweight/obesity for (predominantly non-Indigenous) people living in Major cities.
High blood pressure
Table 17: High blood pressure, people 18+, by Remoteness, 2014-15
Age for age, people in rural/regional Australia appeared to be as likely, or very slightly more likely to have high blood pressure than their counterparts in Major cities (~23% vs ~24%). However, because people in rural/regional areas are older (on average), the prevalence of people with high blood pressure is higher (~26% vs 22%) than
” This National Aboriginal and Torres Strait Islander Health Plan 2013–2023 report presents data for each of the 20 goals, and assesses progress against the goals at the national level.”
In October 2015, the Australian Government released the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023.
The Implementation Plan outlines the actions to be taken by the Australian Government, the Aboriginal community controlled health sector, and other key stakeholders to give effect to the vision, principles, priorities, and strategies of the National Aboriginal and Torres Strait Islander Health Plan 2013–2023.
The Implementation Plan has set goals to be achieved by 2023 for 20 indicators.
These goals were developed to complement the existing COAG Closing the Gap targets, and focus on prevention and early intervention across the life course.
” The communication gap between health professionals and Indigenous Australians has a significant impact on health outcomes
Limited health literacy is not confined to Indigenous people, but it is greatly magnified for speakers of Indigenous languages in comparison, for example, to non-English speaking migrants from countries where a scientific approach to medicine is practised and where these health concepts are already codified.”
Dr Robert Amery Medical Journal Australia NAIDOC Week 2017
Introduction Press Release
Communication gap puts Indigenous health at risk
The need for health professionals to have a stronger focus on communication with Indigenous people has been highlighted by the University of Adelaide’s Head of Linguistics, who says some lives are being put at risk because of a lack of patient-doctor understanding.
In a paper published (Monday 3 July) in the Medical Journal of Australia– coinciding with the NAIDOC Week theme of Our Languages Matter – Dr Robert Amery has raised concerns not just about language but also a lack of cultural awareness that also impacts on good communication with Indigenous patients.
Dr Robert Amery, who heads Linguistics within the University of Adelaide’s School of Humanities and is a Kaurna language expert, says poor communication can lead to “mistrust and disengagement with the health sector” among
Indigenous patients, leading to a lack of compliance with treatment, and ultimately poor health outcomes.
He says there’s a 16-year gap in life expectancy for Indigenous people living in the Northern Territory compared with non-Indigenous Australians. Of these Indigenous people in the NT, 70% live in remote areas, and 60–65% speak an Indigenous language at home.
“While many speakers of Indigenous languages living in remote areas can engage with outsiders and converse in English about everyday matters, they often have a poor grasp of English when it comes to health communications and other specialised areas,” Dr Amery says.
Miscommunication can be subtle, and previous studies have shown that while both parties think they have understood each other, they can in fact come away with very different understandings.
“Miscommunication isn’t just about language. Some of these difficulties also arise from the interface of communication and culture, which are often derived from differences in worldview,” he says.
“For traditionally oriented Aboriginal people living in remote areas, understanding of disease causation is fundamentally different. Serious diseases, even accidents, are often attributed to sorcery. Germ theory and the immune system are foreign concepts.
“Silence plays an important role in Indigenous cultures. Indigenous people often respond to questions after a prolonged pause, a concept foreign to those doctors who see silence as impolite in their own cultures.
They compensate by filling the silence and disrupting Indigenous patients’ thoughts. There is a simple solution: pause and allow the patient to think.”
He also suggests healthcare professionals avoid the use of “intangible” conceptual English words and vague sentences, instead focusing on factual communication; that they demonstrate how a medical procedure works; and use simple diagrams to explain medical issues.
“These examples may seem plain and obvious, but astoundingly, despite the many hours dedicated to communication in medical education, such concepts are not taught,” Dr Amery says.
“An investment of time in the consult will have immense payoffs over the long term.”
The communication gap is most pronounced in remote areas where cultural and linguistic differences are greatest. The close interdependence of language and culture amplifies the gap, such that communication difficulties in these communities run deeper than language barriers alone.
Life expectancy for Indigenous Australians living in remote areas is considerably shorter than for those living in rural and urban areas.6 Figures are not available for the life expectancy of native speakers of Indigenous languages as a cohort, but the gap in life expectancy exceeds 16 years for Indigenous people living in the Northern Territory,7 70% of whom live in remote areas, and 60–65% speak an Indigenous language at home. The life expectancy gap is, of course, multifactorial, although most studies focus on causes of death.8 The communication gap as a contributor is under-rated and under-researched.1,9
An understanding of the Indigenous language landscape is critical to improving communication. In the 2011 Australian census, 60 550 people, or 11.8% of Indigenous respondents, claimed to speak an Indigenous language at home, and 17.5% claimed not to speak English well.10
More have difficulty with specialised language, with common terms such as infection, tumour, high blood pressure, stroke and bacteria often misunderstood. Native Indigenous language speakers communicate in over 100 different traditional languages and live primarily in the NT, the Kimberley region of Western Australia, northern South Australia and northern Queensland, including Torres Strait.
None of these languages have more than 6000 speakers, and many are now reduced to a mere handful, yet each of these languages is a vast storehouse of knowledge built up over thousands of years. It can be daunting to enter a large English-speaking hospital if you communicate in a language spoken by so few people.
Speakers of some languages have shifted to dominant regional languages, such as Murrinh-Patha (Wadeye, NT), while others have shifted to a creole language, such as Kriol (the Kimberley region and the Barkly Tableland area of the NT and North West Queensland).
Aboriginal people often speak distinctive varieties of Aboriginal English that differ from mainstream English. For most Aboriginal people in remote areas, their Aboriginal English is an inter-language variety, in the same way that Japanese speakers have their own distinctive accent and turn of phrase in English, which may be a challenge for medical personnel to understand.
Data might suggest that only a small proportion (less than 10%) of Indigenous adults under 60 years do not speak English well, and that communication issues would therefore not be significant (Box 1).
However, while many speakers of Indigenous languages living in remote areas can engage with outsiders and converse in English about everyday matters, they often have a poor grasp of English when it comes to health communications and other specialised areas. In a study on comprehension of 30 common legal terms (assault, bail, guilty, warrant, etc),11 200 Yolŋu people (north-east Arnhem Land) were surveyed with over 95% unable to correctly identify the meaning of these terms (Box 2).
A parallel health study has not been conducted, but it is likely that understanding of common specialised health terms would be no better. Personal experience supports this view. In 1990, I taught a short course in medical interpreting to a group of Yolŋu students. In teaching the difference between idiomatic and literal language, I introduced an example (“He chucked his guts up”) that I thought everyone would understand. The Yolŋu students interpreted this idiom literally, thinking he ripped out his intestines and threw them in the air. Even simple little things that might be said, such as “let’s keep an eye on it”, can be baffling, because these expressions are often taken literally.
Proportion of Indigenous Australians who speak an Indigenous language and who are reported to speak English “not well” or “not at all”, 2006 and 2011*
Yolŋu comprehension of 30 common legal terms*
Misinterpretations also arise from the interface of communication and culture, here derived from differences in worldview rather than linguistics. In the 1980s, I talked with Tjapaltjarri (skin name, now deceased), a senior Pintupi Aboriginal health worker, about the location of a relative’s house in Alice Springs. Tjapaltjarri referred to various landmarks such as trees and rocks. I asked him about prominent street names including Bloomfield Street. We conversed with full understanding, but I could not follow Tjapaltjarri’s directions. I never paid attention to these landmarks, he never noticed street names. This was not a linguistic issue. It was literally a matter of different worldview. Extrapolate from this example to appreciate the difficulties first language speakers of Aboriginal languages might have in following medical explanations, even when they seemingly speak good English.
These communication gaps are confirmed in health settings. A study of Yolŋu patients undergoing dialysis in Darwin2 identified, through exit interviews, significant misunderstanding of test results despite both patient and renal nurse having revealed that they were satisfied with the communication.
Trudgen9 discusses a Yolŋu patient suffering from severe diabetes and renal failure who was able to avoid dialysis once his condition was explained to him in meaningful terms, and goes on to estimate that 75–95% of communication with Yolŋu patients fails, even with an Aboriginal health worker involved. Aboriginal health workers are not necessarily trained interpreters, nor is interpreting their primary role, although they are often expected to interpret.
How do we improve? Surprisingly simple communication methods, which are easy to teach within mainstream medical education, can help. Trudgen demonstrates how to explain to a Yolŋu patient their 2% residual renal function.9 Many Yolŋu and speakers of other Indigenous languages do not understand the concept of percentages. A picture of a kidney was drawn, shading in the 2% still functioning and showing the remainder, which was sclerosed (Box 3). The patient responded in shock and, no doubt, with better dialysis participation.
Box 3
Template to explain residual renal function of 2% (hatched area) in an otherwise sclerosed kidney (dots)
Aboriginal patients may not be as trusting of medical implements as others. Refusal of an ear examination, for example, may be overcome by allowing such a patient to look through the otoscope to understand how it works. Silence plays an important role in Indigenous cultures.9,12,13
Indigenous people often respond to questions after a prolonged pause, a concept foreign to those doctors who see silence as impolite in their own cultures. They compensate by filling the silence and disrupting Indigenous patients’ thoughts. There is a simple solution — pause and allow the patient to think.
Studies1,2,3,4,14 have identified a widespread belief among Yolŋu people that information is deliberately withheld, mirroring culturally based misconceptions that lead many professionals to believe that Aboriginal patients do not want to know or that they do not experience pain.15
However, several studies1,4,14 clearly demonstrate the desire of Aboriginal people, both from the Top End and from Central Australia, for information about their illnesses and treatment. Effective communication methods, including the use of interpreters, are grossly underutilised, and frequently there is a failure to recognise that patients do not understand.
In a study of 41 Yolŋu people, only 11 found explanations about diagnosis and treatment satisfactory.4 Other studies have shown that even when patients are satisfied, gross misunderstandings may still exist.2 Trudgen9 again gives an example of how this may occur. A doctor explained to a patient that he “could not tell conclusively why [the patient’s] heart was enlarged”. The patient subsequently interpreted this to be that the doctor had no idea why his heart was enlarged and decided not to engage in treatment. Had the doctor avoided use of “intangible” conceptual English words and vague unrevealing sentences, instead focusing on factual communication, this error could have been avoided.
A failure to develop an adequate understanding does run deeper than words. For traditionally oriented Aboriginal people living in remote areas, understanding of disease causation is fundamentally different. Serious diseases, even accidents, are often attributed to sorcery.16,17 Germ theory and the immune system are foreign concepts.
Traditionally oriented Aboriginal people typically have detailed knowledge of anatomy from hunting, butchering and observing nature,9,18 but the perceived function of the kidneys, lungs, pancreas and other internal organs may be quite different. Finding common ground between these understandings is no easy task, but it is important to understand that it may play into medical treatments in the same way as having insight into the use of alternative medicines does in other cultures.
These examples may seem plain and obvious, but astoundingly, despite the many hours dedicated to communication in medical education, such concepts are not taught. Some strategies are provided in Box 4. There is an urgent need to pay more attention to communication needs of remote Aboriginal people.
Communication strategies
A refusal to take Aboriginal languages seriously not only results directly in less than optimal medical outcomes, but also in mistrust and disengagement with the health sector and non-compliance with treatment regimens.3
An investment of time in the consult will have immense payoffs over the long term. We cannot expect our medical students and colleagues to adapt without teaching.
Concepts are simple to grasp with knowledge of the languages and cultures. Is effective establishment of the Aboriginal patient–doctor relationship not one of the more teachable aspects of communication for generations of doctors?
Education is the way forward to a practical and high impact population of medical staff who contribute to the health and pride of the people who are Australia’s national treasures.
” The National Rural Health Alliance has been leading advocacy to the Government that it is time to develop a new Rural and Remote Health Strategy, together with a fully funded Implementation Plan.
In developing its thoughts on the need for a new Strategy and its contents, the Alliance is developing a series of discussion papers, with the first now available – considering the reasons why we need a new Strategy and what has been achieved under the 2011-12 Strategy.”
This paper has been prepared to stimulate discussion on an issue of importance to rural and remote health.
The views and opinions in the paper do not necessarily represent those of the National Rural Health Alliance or any of its Member Bodies.
For The National Rural Health Alliance’s new own Strategic Plan just released and spanning the period 1 July 2017 – 30 June 2019
The Alliance intends to focus on seven priority areas including: Improving the health outcomes for Aboriginal and Torres Strait Islander Peoples;
There is no point in continuing to reference a Framework that is not in use and that is deeply flawed (see background 1 below and in download ) . Whatever document replaces the Framework, it must include outcome measures and set indicators to measure progress against the most pressing needs.
And there must be annual reporting against those outcomes to enable jurisdictions to consider how they are progressing and fine tune their responses as necessary.
Ideally, a new National Rural and Remote Health Strategy should be developed with stakeholder input and introduced with a fully funded Implementation and Evaluation plan.
This should include, but not be restricted to, a rural and remote workforce plan – as pointed out throughout this report, the solutions needed to bridge the divide in the health and wellbeing of the city and the bush deserves and requires far more.
We need concrete, on-the-ground actions, which make a positive difference in the lives of individuals, families and communities in rural and remote Australia.
The Alliance has been an active participant and co-signatory in the development of previous strategies and plans, and stands ready to fulfil that role again.
We must learn from the past and strive to address the inequity of health outcomes that are experienced by the seven million people living outside Australia’s major cities
Background 1 of 2
The National Strategic Framework for Rural and Remote Health (the Framework) was developed through the Rural Health Standing Committee, a committee of the Australian Health Ministers’ Advisory Council, and agreed by the Standing Council on Health, the committee of Ministers of Health, in late 2011. It was launched in 2012. The Framework was developed through a consultative process that included significant input from the National Rural Health Alliance (the Alliance) and other rural and remote health stakeholders, including State and Territory governments.
While the Framework can be accessed through the Department of Health website, it is not in use. No reporting has ever been undertaken to present an update on progress, recognition of the range of policies and programs implemented by Commonwealth, State or Territory Governments to address the goals of the Framework, or to examine the effectiveness of the Framework in addressing those goals.
Further, the health workforce strategy developed as a companion document to the Framework – National Health Workforce Innovation and Reform Strategic Framework for Action 2011–2015 – is also no longer in use, having been archived when the Health Workforce Agency was disbanded in 2014.
At the time, the Alliance called for a National Rural and Remote Health Plan to be developed to operationalise the Framework, but this never eventuated.
The role of a comprehensive Framework to guide and direct better health outcomes in rural and remote communities is critical. Where players from communities, jurisdictional and private health providers and federally-funded organisations come together to meet the challenges of delivering health services in rural and remote communities, it must be through a shared understanding of the issues and a clear vision for the future.
At the outset, the Framework acknowledged that the people who live in rural and remote Australia “tend to have lower life expectancy, higher rates of disease and injury, and poorer access to and use of health services than people living in Major cities”.
Drawing on the Australian Institute of Health and Welfare publication Australia’s Health 2010, the Framework identified key areas of concern with regard to the health of people in rural and remote communities, particularly:
higher mortality rates and lower life expectancy;
higher road injury and fatality rates;
higher reported rates of high blood pressure, diabetes, and obesity;
higher death rates from chronic disease;
higher prevalence of mental health problems;
higher rates of alcohol abuse and smoking;
poorer dental health;
higher incidence of poor ante-natal and post-natal health; and
higher incidence of babies born with low birth weight to mothers (in very remote areas).
The Framework does not include data quantifying these concerns. In referring back to Australia’s Health 2010, the data used to describe the health of people in rural and remote Australia is from 2004-2006 – it was already up to six years old at the time the Framework based on it was launched. It is very difficult to plan appropriately to address inequality when data is this out of date.
Perhaps the biggest gap in the Framework is that it does not link the inequities it identifies in rural and remote health generally to the five goals it develops. While this is largely due to a lack of narrative, what this lack of narrative does is lose the unifying rationale for the five goals and how they will work together to make a difference to the inequities identified in the Framework. If this was simply a lack of a coherent narrative to drive the needed policy responses, it may be excusable. But unfortunately, the lack of this coherent narrative has resulted in:
lack of recognition of the need for baseline indicators against which progress can be measured and reviewed;
loss of the connectedness of the goals – at the Commonwealth level we now see rural health reduced to workforce policy responses without a clear understanding of how those responses will actually lead to improvements in health outcomes and the range of health inequities in rural and remote communities; and
undermining one of the most crucial needs underpinning the Framework as a whole – the need for quality and TIMELY data. The lack of good quality, current, data is apparent as soon as you begin to seek answers to the question “what has the Framework achieved?”
In developing this Discussion paper, the Alliance is seeking to undertake a high level, selective assessment using publicly available data to ascertain to what extent progress is being made in addressing health concerns and inequities in rural and remote Australia, referencing back to the goals and outcomes set out in the Framework.
Where related specific programs stemming from the Framework can be identified and their outcomes assessed, this will be included in the discussion. Given there are nine specific issues identified in the Framework and set out in dot point format above, the Alliance will seek information on only three to discuss whether any change in outcomes following the implementation of the Framework can be assessed accurately, and if so, what outcomes were achieved.
Background 2 of 2
The National Rural Health Alliance’s new Strategic Plan has been released and spans the period 1 July 2017 – 30 June 2019.
It is a high-level document to set directions, priorities and key areas of activities over the coming two years. It also includes measures of success and effectiveness, identified as process, impact and health outcomes.
The Alliance intends to focus on seven priority areas including:
Unlocking the economic and social potential of the 7 million people living in rural and remote Australia;
Improving the health outcomes for Aboriginal and Torres Strait Islander Peoples;
Integrating teaching, training, research and development to attract and retain the right workforce;
Strengthen prevention, early intervention and primary health care;
Developing place-based, community and individualised local approaches to respond to community needs;
Reducing the higher burden of mental ill-health, suicide and suicide attempts; and
Securing long-term, sustainable funding to extend our core work.
These seven priority areas have been strongly influenced by the recommendations coming out of the recent 14th National Rural Health Conference held in Cairns. Further, these are all areas in which the Alliance believes further efforts and advocacy is required to improve the health and wellbeing of people living in rural and remote Australia.
A common link across all these priority areas is the need for a National Rural and Remote Strategy and associated Implementation Plan. The Alliance will work with members and other stakeholders in the pursuit of such a Strategy and Plan.
The Alliance is currently developing a workplan that will guide specific work streams.
” As you are aware, the Medicare Benefits Schedule (MBS) Review Taskforce is considering every one of the more than 5,700 items on the MBS, with a focus of how the items can be better aligned with contemporary clinical evidence and practice to improve health outcomes for all Australians.
Diagnostic Imaging – pulmonary embolism and deep vein thrombosis
Renal Medicine
Spinal Surgery
Urgent after-hours primary care services funded by the MBS
Examples
The online survey is open from today until Friday July 21, 2017.
It is important to note that these recommendations are not final and are being released publicly for the purpose of obtaining stakeholder feedback.
Your input as a stakeholder is critical in shaping the Review. Please use the online surveys (rather than emailing your comments directly) for accuracy and transparency when analysing your feedback.
If you have any questions or queries on the Review or the work of the Taskforce please contact the MBS Review Team.
” This fourth national report on the Indigenous primary health care national Key Performance Indicators (nKPIs) data collection presents annual data on indicators collected from the June 2012 to the June 2016 reporting period.
Information is presented for 22 ‘process-of-care’ and ‘health outcome’ indicators for June 2016, which focus on maternal and child health, preventative health, and chronic disease management.
The report shows continuous improvements for the majority of indicators.
Yes the good news is , improvements were seen in 12 of the 16 process-of-care measures for which time trend data were available (Table S1 below ).
For 10 of these measures, the change was statistically significant.”
Data for this collection are provided to the AIHW by primary health care organisations that receive funding from the Department of Health to provide services to Aboriginal and Torres Strait Islander people.
Some primary health care organisations that report receive additional funding from other sources, including state and territory health departments, while a small number are funded solely by the Northern Territory Government (see ‘Chapter 1 Introduction’).
The purpose of the nKPIs is to support policy and service planning at the national and state/territory levels, by monitoring progress and highlighting areas for improvement.
The nKPIs can also be used to improve the delivery of primary health care services, by supporting continuous quality improvement (CQI) activity among service providers.
Over the period June 2012 to May 2015 (the period for which time trend data are available), improvements continue to be made across the majority of measures—indicating that health organisations continue to show progress in service provision.
The good news
Improvements were seen in 12 of the 16 process-of-care measures for which time trend data were available (Table S1).
For 10 of these measures, the change was statistically significant. The largest improvements (between 16 and 19 percentage points) were seen in data recording practices for the measurement of:
alcohol consumption, which rose from 38% in June 2012 to 57% in May 2015
birthweight, which rose from 51% in June 2012 to 69% in May 2015
smoking status, which rose from 64% in June 2012 to 80% in May 2015.
Results for process-of-care measures related to Medicare Benefits Schedule (MBS) health assessments (for children and adults) exceeded the 2016 trajectory of the Implementation Plan goals for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023.
Improvements were also seen in 3 of the 5 health outcomes measures for which time trend data were available. For 1 of these, the change was statistically significant:
• Health of clients with type 2 diabetes—those with an HbA1c (glycosylated haemoglobin), with a result of ≤7% in the previous 6 months, rose from 32% in June 2012 to 35% in May 2015. (An HbA1c result of ≤7% is the optimum target encouraged by Diabetes Australia to ensure good glycaemic control and reduce the incidence of diabetes-related illness.)
Things to work on
Results for 3 process-of-care measures related to immunisation against influenza—clients aged 50 and over; clients with type 2 diabetes; and clients with chronic obstructive pulmonary disease (COPD)—and for the 1 process-of-care measure relating to cervical screening saw small decreases of between 1.3 and 2.6 percentage points. However, these were not statistically significant.
Results for 2 health outcome measures showed increases: the proportion of babies born with a low birthweight increased by 0.9 percentage points and people whose body mass index (BMI) score classified them as overweight or obese increased by 4.3 percentage points.
However, these increases were not statistically significant.
These results also remain in line with national data for Indigenous Australians.
