” I’m keen to hear your ideas on how we can cooperate across the sector to develop a better workforce with cultural safety embedded throughout the hundreds of clinics and hospitals across the country.

I was impressed by the theme you chose for your conference: ‘connecting care through culture’. That simple phrase captures so much of what we do in our sector each and every day.

Cultural safety, I believe, is what makes us unique and what represents our greatest strength.

In the Aboriginal community-controlled health organisations – the ACCHOs – you have this reinforced through the operating model.

‘Community control’ is not just a term – it is a 48-year-old model – forged at Redern in 1971 – and now exercised in 144 local Aboriginal and Torres Strait Islander communities across the country.” 

Donnella Mills Acting Chair, NACCHO Keynote address at the CATSINaM National Professional Development Conference Sydney 26 September 

I would like to acknowledge that this conference is being held on Aboriginal land. I recognise the strength, resilience and capacity of the Gadigal people of the Eora Nation who are the traditional custodians of this place we now call Sydney. I pay my respects to their elders.

For those of you who don’t know me, I am a Torres Strait Islander woman with ancestral and family links to Masig and Nagir. I am the Acting Chair of NACCHO, which stands for the National Aboriginal Community Controlled Health Organisation.

I thank the CATSINaM Board for inviting me to deliver this address. It is a privilege to be talking with you today and a special pleasure to be among so many hard-working and dedicated healthcare professionals.

Without you, the Health gap would be so much wider than it is now. Without you, there would be little cultural safety in our hospitals and medical services. I have seen how important your work is on the ground at Wuchopperen and in the other services I have visited. You are the backbone of Aboriginal health.

I plan to speak for about 25 minutes. That will leave us about 20 minutes for yarning at the end. I’m keen to hear your ideas on how we can cooperate across the sector to develop a better workforce with cultural safety embedded throughout the hundreds of clinics and hospitals across the country.

Community control

Our people trust us with their health. We build ongoing relationships to give continuity of care so that chronic conditions are managed and preventative health care is effectively targeted.

Studies have shown that Aboriginal controlled health services are 23% better at attracting and retaining Aboriginal clients than mainstream providers.

Through local engagement and a proven service delivery model, our clients ‘stick’. The cultural safety in which we provide our services is a key factor of our success. In this way, ACCHOs are already ‘leading the way’.

We also build partnerships that make things work. Leadership is not all about the strength to stand up on your own, it is about being smart enough to stand shoulder-to-shoulder with one another. It is about galvanising support on the ground. It is about forging alliances in the sector and building strategic partnerships at the national level.

Employment

Another strength – one that we tend to overlook – is the sheer size of our sector. Let’s have a look at the ACCHO part of it alone. It is not widely known, but the 144 ACCHOs, collectively, are the single largest employer of Aboriginal and Torres Strait Islander people in Australia. That means that one in every 44 Indigenous jobs in Australia is at one of our health services.

If we add the Aboriginal health workers in the mainstream and the rest of the sector, these numbers become all the more impressive.

Our sector is doing more to close the employment gap than any of the employment measures dreamed up by Government agencies.

If the Government really wants to get people off welfare, don’t punish vulnerable people with cashless welfare cards, robo-debts or by sending them off to meaningless Work for the Dole activities.

Work with our sector and grow the Aboriginal workforce together. We have real jobs located in real communities. That is where the investment needs to go.

We should remind our politicians of this when they visit us.

They may see a small clinic somewhere with a few staff, but if they understood that we are part of a huge national network of Aboriginal professionals, they might take more notice of us and realise what we have to offer.

Comprehensive primary health care

Another challenge for us is continuing the development of a comprehensive primary health care model. I think we have been hearing this since the release of the National Aboriginal Health Strategy way back in 1989.

Twenty-one years later, a study concluded that ACCHOs are one of a very few settings where ‘comprehensive primary health care’ is delivered. If we keep offering a comprehensive approach for primary health care across the nation, our people will be much less likely to fall between the cracks.

We can do this through colocation of services or forming partnerships at the local level. This can include clinical care, immunisation and environmental health programs, on-site pharmaceutical dispensing and partnerships with family violence, child protection counselling and legal services.

We can also develop links with sports programs, homelessness services, dental services, aged care and disability support. None of these elements can fully succeed when they stand alone. The voluminous literature on the social determinants of health tell us that. But more importantly, it is what we all know from our own personal experiences.

You don’t need an academic to tell you that comprehensive primary health care is the best approach. We all know this intuitively and from our experiences on the ground.

I am not saying that we should all diversify or ‘dilute’ what we are doing. What I am saying is that while we focus on our core activities, we should also be taking every opportunity we can to link up with other Aboriginal and Torres Strait Islander services and programs in complementary areas.

From my own experience ….

When you think about it, it should not be hard to promote ourselves; to sell ourselves to a new Government. After all, we provide value for money. ACCHOs result in greater health benefits per dollar spent; measured at a value of $1.19 for every $1 spent.

Studies have also shown that the lifetime health impact of interventions delivered by ACCHOs is 50% greater than if these same interventions were delivered by mainstream health services. This is primarily due to improved Aboriginal access and outcomes.

I don’t need to tell you that we also have some pretty significant challenges ahead of us. And I’d like to address these now, one by one.

Remuneration

If we are serious about workforce development, then we cannot ignore the issue of wages. Correct me if I am wrong, but from what I have heard, remuneration is a big issue for nurses and midwives. The ALP, as part of its election platform in May of this year had much to say about improving wages and conditions in the childcare sector, and justifiably so. Childcare is another industry in which women dominate, but are underpaid.

We need the Commonwealth and State Governments to take a similar approach to nurses and midwives. As you all know, women make up almost 90% of all employed nurses and midwives. Representative bodies like NACCHO and CATSINaM need to work together to drive this message home to Governments across the country. Remuneration is an important aspect in attracting and retaining staff.

Vocational development

I think we need to keep improving the career development opportunities and skills acquisition not just for nurses and midwives, but for all Aboriginal health workers. Currently, there is an imbalance in the medical services in which we see more Aboriginal people on the lower levels and amongst the non-clinical staff.

The graph in my presentation shows the situation for ACCHOs. We need more Aboriginal non-clinical staff but we need even more Aboriginal clinical staff.

Recruitment

I see that CATSINaM has a proud record in increasing its membership in recent years. I think you had a record number in your 2018 Annual Report – 1,366 members – representing a jump of 35%. Clearly, you are doing something right to have recruited so many new members.

You must have won the trust of your members to have such a healthy and expanding membership base. With almost half of the Aboriginal and Torres Strait Islander nurses and midwifes in Australia as your members, CATSINaM is the key organisation in addressing many of the workforce development issues in our sector.

Certainly, much more needs to be done to develop career pathways to secure more Aboriginal and Torres Strait Islander nurses and midwifes as well as more doctors and allied health professionals.

Across Australia in 2015 the AIHW reported that there were only about 180 medical practitioners, 750 allied health professionals, and 3,200 nurses (including 230 midwives) who identified as Aboriginal or Torres Strait Islander people. For nurses, this represents just over 1% of all employed nurses and midwives Australia-wide.

The Northern Territory (2.4%) and Tasmania (2.2%) had the highest proportion of Aboriginal nurses and midwives, while Victoria had the lowest (0.5%). Compare these figures to our proportion of working-age Australians – close to 3.%. We should have 3% of all nurses and midwives, not 1%.

As I have already said, our sector is the largest employer of Aboriginal and Torres Strait Islander people across the country.

Now, if the ACCHOs as a group employ about 6,000 staff, of which 56 per cent are Aboriginal or Torres Strait Islanders, then we still have another 2,500 jobs in our own sector which could be filled by Aboriginal and Torres Strait Islander people.

We have a significant opportunity here. Think of what we could do for our people if we filled such a large number of jobs.

Retention

A big challenge that we confront every day – particularly in the bush – is retention. Stress and burnout is a real problem as Fran Baum’s research has shown. Turnover of staff is high and vacancies remain unfilled for longer than we would like.

With so many vacancies, particularly in remote clinics, a concerted effort could also have a significant positive impact on the size and health of our workforce. It is troubling to hear of the high reported vacancy rate of 6% (i.e. about 380 vacancies at any point in time).

Nevertheless, ACCHOs are doing pretty well in comparison with mainstream and non-Aboriginal organisations. The proportion of health vacancies was 6% compared with 9% for other organisations. My guess is that it is cultural safety that explains the advantage here.

So, if we have a good model and we have sector already working hard for Aboriginal health, then how are we going?

Life expectancy target not met

If we look at just one of the ‘Closing the Gap’ targets – life expectancy – you can see how stark the differences are. According to ABS data, which probably overestimate Aboriginal life expectancy, non-Aboriginal Australians can expect to live to about the age of 82. Aboriginal and Torres Strait Islander people are lucky to make it to 72. T

hat’s a ten-year difference. We would be better off living in other countries where the life expectancy is higher. Countries – believe it or not – like Bangladesh or Azerbaijan. Life expectancy is longer in some Third World countries than it is for our people.

Funding for Aboriginal health has fallen

Despite all the words we have heard from Commonwealth and State Governments over the years about ‘Closing the Gap’, instead of increasing expenditure, Governments have actually decreased expenditure on Aboriginal health over the past decade.

Governments need to spend two to three times more on Aboriginal health if we are to have a level of funding commensurate with the actual cost of the burden of disease. This is a huge sum – about $1.4 billion per year – on one estimate.

In real terms health expenditure (excluding hospital expenditure) for Aboriginal people fell 2% from $3,840 per person in 2008 to $3,780 per person in 2016. Over the same period, expenditure on non-Aboriginal people rose by 10%. How can you expect to close the gap when you are reducing funding for our people and increasing it for the non-Aboriginal population?

If we act as one, we can turn things around.

Look at the way that the Aboriginal peaks, like NACCHO and CATSINaM, stood together to force the nine Australian governments to restart the Closing the Gap process. Before we came together and complained to them, the consultation process was expensive lip service.

Before we stood together with one voice, our separate voices were ignored. Now they are listening. Now things are back on track.

Funds are tighter than ever to procure, but, over the years, we have built a world class model of health care and there is too much at stake for us now to start drifting backwards now.

The timing is critical, especially now that we have a re-elected Government and the new arrangements in the administration of Aboriginal programs. It is great to see Ken Wyatt as the first Aboriginal Cabinet member as the Minister for Indigenous Australians.

But we need to engage as closely as we can with him and with Minister Hunt. We also need to keep the dialogue open with Senator Dodson, Senator McCarthy and the Member for Barton in NSW, Linda Burney.

There are also plenty of good Aboriginal leaders in the State and Territory Governments and I urge you to keep talking to them. It is important to have our voice heard.

Especially when we face a mainstream system that continues to overlook us; especially when we have a mainstream system that continues to patronise us. If we don’t act now and keep the pressure up, we will lose some of our recent hard-won gains.

The future

Despite the appalling funding neglect for programs and the low wages paid to our health workers, you have shone in adversity. You are resilient. You survive despite whatever circumstances you find yourselves in.

It’s self-determination and the need to control our own health programs that led to the ACCHO model of care in the first place. It is a lesson for our sector.

If the system was working now, we would have zero preventable hospital admissions. The evidence is not just here, it is overseas as well.

In Canada it has been shown that First Nations communities that transitioned from government-control to community-control of health services experienced a 30% reduction in hospitalisation rates compared with communities where government control was maintained.

In a perfect world our model of primary care through community control would also be complete. We would have full coverage across the land.

We would also have an Aboriginal NDIS workforce in fully-funded models for disability services rolled out, Australia-wide.

And of course, all this hinges on a more accountable public health system and an uncapped needs-based funding model. Who knows, if we had all these things, we may even seriously imagine a future in which we have actually closed the health gap.

With Aboriginal health in Aboriginal hands I know that we can get there eventually.

NACCHO and CATSINaM can continue to work together and to set the way forward for Aboriginal health.

But we can also show the non-Aboriginal population what is possible. It is this future that I imagine for my daughter and my own family.

I am sure that it is a vision that we all share.

Leading the way for all of Australia through cultural safety and respect.

Have your say about what is needed to make real change in the lives of Aboriginal and Torres Strait Islander people #HaveYourSay about #closingthegap

There is a discussion booklet that has background information on Closing the Gap and sets out what will be talked about in the survey.

The survey will take a little bit of time to complete. It would be great if you can answer all the questions, but you can also just focus on the issues that you care about most.

To help you prepare your answers, you can look at a full copy here

The survey is open to everyone and can be accessed here:

https://www.naccho.org.au/programmes/coalition-of-peaks/have-your-say/