” I can recount ‘hundreds’ of similar experiences and that ‘every Aboriginal person’ would have comparable stories – Aboriginal ethnicity is the strongest predictor of Discharge Against Medical Advice ( DAMA )and occurs at a rate eight times that of the non-Indigenous population.
I am trying to encourage health services to take more responsibility by getting them to ‘look at it in a different way’, as i believe it is incumbent upon health professionals, including GPs, to lead the fight against racism.
[I want them] to think what is so toxic about this environment … [where] they know if they walk out that front door they could die and they’d rather do that than stay in here.
Everyone in the health system should be advocating for their patients, but GPs are perfectly placed to do that.
Our patients trust us more than any other doctor that they see and they have an intimate, ongoing relationship with us that they don’t necessarily have with any other health professional.
Creating a safe environment for our patients is exactly our responsibility … it’s just about showing an extra level of care for patients and ensuring that they’re comfortable in order to help make a wider change.’
Associate Professor O’Mara highlighted disproportionately high rates of Discharge Against Medical Advice (DAMA) events experienced by Aboriginal and Torres Strait Islander people as one by-product of discrimination in the health system, but said GPs are well-placed to help prevent such episodes from occurring. Speaking to GPnews
The 12th Closing the Gap report, released in February this year, laid bare the lack of progress Australia continues to make with regard to improving Aboriginal and Torres Strait Islander health, education and employment outcomes.
Child mortality is twice that of non-Indigenous children, the life expectancy gap remains at about eight years (and equivalent to developing countries like Palestine and Guatemala), and there is a burden of disease 2.3 times greater than that of non-Indigenous Australians.
According to the Coalition of Peaks, which this week released what it called a ground-breaking report into the development of a new National Agreement on Closing the Gap, a change in approach is required to ‘truly close the gap in life outcomes between Aboriginal and Torres Strait Islander people and other Australians’.
It advocates for more Aboriginal and Torres Strait Islander involvement across the board, and calls for mainstream service delivery – including the health sector – to be reformed to address systemic racism, promote cultural safety, and to be held ‘much more accountable’.
Associate Professor Peter O’Mara, Chair of RACGP Aboriginal and Torres Strait Islander Health, told newsGP that differences in health outcomes are ‘absolutely’ linked to systemic and institutionalised racism in Australia, as is the subsequent trauma it inevitably produces.
View previous NACCHO TV Interview with Associate Professor Peter O’Mara
One of the greatest sources of trauma for Aboriginal and Torres Strait Islander people, according to Associate Professor O’Mara, is their interaction with police and the criminal justice system.
‘I went up to a town in the Northern Territory many years ago and when I got to the community a young fella had just been taken across to Darwin where he was spending two weeks in incarceration [due to mandatory sentencing laws].
‘What had happened is, he and his mates were playing cricket on the street … and this young fella had the bat, hit a big shot, and smashed a streetlight.
‘Someone has complained and said, “I’m calling the cops”. He waited and did the right thing, he said, “Look, I’m really sorry, it was an accident, we were playing cricket. I’m sure my parents will try and help pay for the light”, but he got locked up for two weeks.
‘Just for something silly like that – they were playing cricket on a dead-end street in Australia.’
Associate Professor O’Mara says instances like that only tell part of the story.
‘[For example], there’s the fact that Aboriginal and Torres Strait Islander people are more likely to suffer hearing disorders – often as a result of things like chronic suppurative otitis media – and the evidence is there to say that when you have a hearing disorder, you’re more likely to be incarcerated,’ he said.
‘Some of the things that we do as GPs, like working on that trying to improve ear health for children, and particularly for Aboriginal children, can have a direct impact.’
Dr Penny Abbott, Chair of the RACGP Specific Interests Custodial Health network, said GPs are at the frontline for people who are in contact with the criminal justice system.
‘The reasons people end up in prison usually include health issues, such as mental health or substance-related problems, and social problems like homelessness and lack of community-based support networks,’ she told newsGP.
‘Addressing these issues before people get to the point of being sent to prison can happen at a primary care level where we are good at treating the whole person in their context.’
Dr Abbott also said once a person is released from prison it is a ‘perfect time’ to consider if an Aboriginal health check, mental health plan, or chronic disease management plan is urgently needed.
‘[GPs] can make a real difference to Aboriginal and Torres Strait patients by being aware of the kinds of health, social and system issues that their patient comes up against when leaving prison – a precarious time where people are at high risk of relapse to drug use, death, hospitalisation, and returning to prison,’ she said.
‘For example, GPs can ensure continuity of healthcare started in prison, manage health issues that weren’t addressed in prison, and look afresh at issues that may be cropping up post-release. Substance-use disorders are of course a big issue to be on top of.’
Aside from the incarcerated person, Associate Professor O’Mara said it is also important to be aware of the vicarious trauma that families can suffer, especially if the family member is assaulted while imprisoned, or worse, dies in custody.
Since the 1991 Royal Commission into Aboriginal Deaths in Custody, imprisoned Aboriginal and Torres Strait Islander people have died at a lower rate than non-Indigenous prisoners – although there are no reliable statistics that can be used to calculate death rates in police custody.
A key finding of the royal commission was that Aboriginal and Torres Strait Islander people ‘do not die at a greater rate than non-Aboriginal people in custody’, but rather ‘what is overwhelmingly different is the rate at which Aboriginal people come into custody, compared with the rate of the general community’.
Yet, in the subsequent years, the proportion of Aboriginal and Torres Strait Islander people in Australian prisons has nearly doubled from 14% to 27%. As a result, 437 Aboriginal and Torres Strait Islander people have died in custody in the past 29 years, as opposed to 99 in the 10-year period investigated by the royal commission.
The high incarceration rate means Aboriginal and Torres Strait Islander people are 15 times more likely to end up in prison than non-Indigenous Australians, and thus more likely to die there as well.
Dr Abbott said deaths in custody are a great burden on Aboriginal and Torres Strait Islander communities.
‘We need to remain vigilant and committed to avoiding people being sent to prison in the first place, as well as providing quality care in prison and after release,’ she said.
‘We also need to continually reflect on the root causes of deaths in custody and over-incarceration of Aboriginal and Torres Strait Islander people, the social determinants of poor health and inequities, and the systemic racism that our patients continue to experience.
‘There are many things which will help, such as more programs to divert young Aboriginal and Torres Strait Islander people from prison, and a larger workforce of Aboriginal and Torres Strait Islander people in health and prison health.’
But, as pointed out in the Coalition of Peaks report, institutionalised racism is not restricted to the justice system, and remains a common experience among health professionals and within the health system as well.
Associate Professor O’Mara highlighted disproportionately high rates of Discharge Against Medical Advice (DAMA) events experienced by Aboriginal and Torres Strait Islander people as one by-product of discrimination in the health system, but said GPs are well-placed to help prevent such episodes from occurring.
‘This is a great example, unfortunately, of what happens to our people,’ he said.
‘I’ve seen a gentleman in the clinic in the Aboriginal Medical Service who had chest pain, and I thought that he was having a heart attack – a myocardial infarction. So I started treating him for that and called the ambulance, which took him to a local hospital that … within the health services is known to be blatantly racist.
‘This gentleman goes into the emergency department. He’s quite happy to be there and he’s thankful that he’s receiving the treatment, but some things are said in that environment that are so toxic to him that he decides to pull the ECG leads off, take the IV lines out and walk out the front door.
‘That happens all too commonly in this setting and then at that point, the doctors and nurses, the health professionals will wash their hands of it because we say, “We told them not to go, they chose to go, they signed this [DAMA form]”.’
“We would need to ensure that strong border controls are maintained and that fully resourced and detailed national, jurisdictional and local outbreak plans are in place that ensure integration and coordination between the NT and Commonwealth governments”.
CEO of Aboriginal Medical Services Alliance NT (AMSANT), John Paterson, expressed support for the relaxation of the Biosecurity measures but noted that to do so safely would require a number of safeguards in place. Quote added by NACCHO / AMSANT
“Our mob living in remote communities want to come into major centres to get food, other essential items and medical treatment they cannot get out bush. We want to move about with our kids and family members without having to quarantine for 14 days,”
Northern Land Council CEO Marion Scrymgour said the act “adversely affected” the movement of Aboriginal people living on homelands and outstations in comparison to non-Aboriginal people. See further quotes below
“We all went into this together, and we’ll get out of this together.
We don’t want to see double standards emerging — where people could get a laksa at Parap Markets and a have bet at the pub from June 5, but the community mob are still locked in.”
Central Land Council CEO Joe Martin-Jard said he wanted the Biosecurity Act to be lifted on June 5, a date that coincided with stage 3 of COVID-19 restrictions easing in the NT.
“It is important that we remain cautious in our approach, we don’t want to see COVID-19 entering one of our communities.
Both Indigenous communities and the Government see this as critical. Many Aboriginal and Torres Strait Islander peoples have more complex health needs than other Australians and my primary concern is continuing to keep this virus out of our communities as much as possible.”
Indigenous Affairs Minister Ken Wyatt said Mr Gunner was able to request changes to the NT’s Biosecurity Act at any time, and discussions between the Federal and NT governments were ongoing.
Northern Territory Chief Minister Michael Gunner says travel to the NT’s 76 remote Indigenous communities may be permitted as early as June 5, following discussions with NT land councils and peak Aboriginal health bodies this week.
The Biosecurity Act, barring essential travel to remote NT communities, is scheduled to stay in place until June 18
Mr Gunner said land councils asked him yesterday to lift restrictions on June 5
But the Chief Minister confirmed easing border restrictions would be the last move by the Government
“The NT is the safest place in Australia,” Mr Gunner said.
“Because we are safe, and because we have strict border controls for the NT, we can look at bringing forward the date for the Biosecurity Act restrictions.”
Under the Biosecurity Act, all non-essential travel to remote Territory communities is currently banned and a 14-day isolation period applies for community residents wanting to return home from regional centres.
The restrictions are scheduled to stay in place until June 18 and align with a 90-day public health emergency declaration.
Mr Gunner said Land Councils asked him yesterday to lift restrictions on June 5 and he would now speak to the Commonwealth about the possibility.
Land councils back proposal
Central Land Council CEO Joe Martin-Jard said he wanted the Biosecurity Act to be lifted on June 5, a date that coincided with stage 3 of COVID-19 restrictions easing in the NT.
“We all went into this together, and we’ll get out of this together,” Mr Martin-Jard said.
“We don’t want to see double standards emerging — where people could get a laksa at Parap Markets and a have bet at the pub from June 5, but the community mob are still locked in.”
At the moment, Mr Martin-Jard said people were locked in their own communities with only one shop to visit, and as the weather cooled in Central Australia, it was important residents could leave to buy warmer clothes and other items they needed — without being forced to quarantine for 14 days upon their return.
Northern Land Council CEO Marion Scrymgour agreed.
“Our mob living in remote communities want to come into major centres to get food, other essential items and medical treatment they cannot get out bush. We want to move about with our kids and family members without having to quarantine for 14 days,” she said.
Ms Scrymgour said the act “adversely affected” the movement of Aboriginal people living on homelands and outstations in comparison to non-Aboriginal people.
“Despite the fact that the intent of the biosecurity measures was to protect Aboriginal people — and this was made clear by both the Prime Minister and the NT Chief Minister from the start — there were elements of the process that were unfair to some Aboriginal people, particularly those living on Community Living Areas — those small areas of land excised for the benefit of Aboriginal people from very large pastoral stations,” she said.
‘We should keep the borders to the NT closed’
Ms Scrymgour and Mr Martin-Jard both said they only supported lifting the Biosecurity Act on June 5 if the NT’s strict border restrictions remained in place.
“We want to see some easing of restrictions in the NT, but only if it’s safe and only if they keep the strong Territory border restrictions,” Mr Martin-Jard said.
“That’s a really positive indication it’s pretty safe for our mob to travel in and out of remote communities without needing to quarantine upon return. But I agree with the Chief Minister that we should keep the borders to the NT closed for a while longer,” she said.
Mr Gunner yesterday confirmed easing the NT’s tough border restrictions would be the last move by the Government.
He also said it was unlikely the Territory would open borders with WA and SA before the eastern states.
Feds to rule on the Biosecurity Act
The decision about when to lift the Biosecurity Act is one for the Commonwealth, and Mr Gunner will need to write to Federal Health Minister Greg Hunt asking him to sign off on the proposal.
Indigenous Affairs Minister Ken Wyatt said Mr Gunner was able to request changes to the NT’s Biosecurity Act at any time, and discussions between the Federal and NT governments were ongoing.
“It is important that we remain cautious in our approach, we don’t want to see COVID-19 entering one of our communities,” Mr Wyatt said.
“Both Indigenous communities and the Government see this as critical. Many Aboriginal and Torres Strait Islander peoples have more complex health needs than other Australians and my primary concern is continuing to keep this virus out of our communities as much as possible.”
“Both Federal and State governments, right across the country, need to step up and invest in rural health if they are serious about this.
There have been numerous examples of initiatives developed to improve access to health care in rural and remote areas being extended into urban areas to prop up under-funded services in for the socially disadvantaged.
This has resulted in the unintended consequence of further disadvantaging Aboriginal and Torres Strait Islander people living in rural and remote Australia.
We need continued investment in health infrastructure and services aimed at addressing the disparity in health outcomes between those who live in the city and those who live in the bush… and this extends across both our Indigenous and non-Indigenous populations.
Without this, as a nation we are never going to close the gap, and the divide for the health outcomes of Aboriginal and Torres Strait Island people living in rural and remote Australia will never be addressed.”
Dr John Hall, President of the Rural Doctors Association of Australia (RDAA), said that without access to high quality health services in rural areas, the gap will never close.
” I’m particularly concerned with successive government failure to halve Indigenous child mortality rates.
A lot of this is about access, it’s around health literacy.
It’s also about the holistic care, it’s also around education, housing and a whole range of other things”.
Australia needs to boost hospital and birthing facilities in rural and regional areas in order to overcome entrenched Indigenous health disadvantage, according to Rural Doctors Association of Australia CEO Peta Rutherford told SkyNews .
Another disappointing Closing the Gap Report, released this month [12 February 2020], demonstrates why health care in rural and remote Australia is a key driver to Closing the Gap in health.
“The Government’s Closing the Gap Report 2020 showed that the Gap between Indigenous and non-Indigenous Australians on key health indicators has not closed,” Dr Hall said.
“Two key health-related benchmarks were chosen by the
Government in 2008, with a target of halving the gap in child mortality by 2018, and to close the gap in life expectancy by 2031.
“Neither of these targets are on track.
“The main cause of Aboriginal and Torres Strait Islander child deaths are perinatal conditions such as complications of pregnancy and birth.
“With 85 per cent of these deaths occurring during the first year of life, maternal health and risk
factors during pregnancy play a crucial role.
“Access to quality, culturally safe, medical care is the most direct way of improving these outcomes,” Dr Hall said.
Similarly, life expectancy in Aboriginal and Torres Strait Islander people is strongly influenced by health and health care, with the report attributing 34 per cent of the gap to social determinants (such as education, employment status, housing and income), 19 per cent to behavioural risk factors (such as smoking, obesity, alcohol use and diet), leaving 47 per cent attributed to what is clearly a disparity in health outcomes and associated health care issues.
In rural and remote areas there is a noticeable difference of a more than six year reduction in life expectancy of Aboriginal and Torres Strait Islander males and females, when compared to those living in major cities.
This demonstrates a failure across the board in these key areas, all of which are influenced by the provision of quality health care.
“Clearly we can’t close the gap without a functional health system in rural and remote Australia,” Dr Hall said.
“And this cannot just be solved through funding Aboriginal Medical Services (AMS); the other parts of the health system need to be equally funded to service these communities in order to be able to provide the standard of care that will result in a reduction in the gap in health outcomes.
“We can’t have hospital services downgraded and expect to close the gap.
“We can’t have communities with no access to medical birthing services and expect to close the gap.
“We can’t have people needing to travel hundreds of kilometres to access cancer or surgical treatment and close the gap.
“We need quality rural hospitals, staffed by Rural Generalist doctors, with the skills needed to meet the needs of these communities in both the General Practice and hospital settings, if we are serious about improving health outcomes and actually closing the gap.
” Australia’s Health Revolution is a new three-part documentary series for SBS TV that’ll be hosted by popular UK presenter and journalist Dr Michael Mosley and Australian Indigenous diabetes educator and exercise physiologist, Ray Kelly.
The series will feature people all over Australia, from all backgrounds aged between 18 and 70 who have been diagnosed with diabetes or pre-diabetes and selected to be part of a 12 week program, following a very low energy diet designed to achieve fast weight loss and help stabilise blood sugar levels.
The documentary will explore the big picture of type 2 diabetes in Australia, and the exciting new science behind diet and lifestyle programs that are reversing type 2 diabetes – previously considered incurable.”
“We can turn blood sugar levels within seven days. It is really a matter of days and weeks to really transform someone form going toward the massive complications that come with type 2 diabetes and heart disease and turning them to becoming much healthier,”
Ray Kelly has been running a health program across Australia around the same principles as Dr Michal Mosley in the UK with great success covering some of the toughest areas and working closely with our ACCHO’s /Aboriginal Medical Services (AMS).
The survey has been devised with help from The Charles Perkins Centre (Sydney Uni). The aim of the survey is to get an understanding of the experience of certain health conditions, including type 2 diabetes, from the perspective of (i) Australians and (ii) specifically, health professional’s (those involved in diabetes care and prevention as well as those who aren’t).
What we’ve known for many years is that type 2 diabetes is both preventable and reversible.
While the solution followed in the series is pretty simple-short term calorie restriction and using fresh, wholefoods as ‘medicine’- presenters want to highlight that low calorie diet programs aren’t routinely offered by most GPs or funded by Medicare.
Ray Kelly says that the TV series cannot come soon enough as Type 2 Diabetes is the fastest growing condition in the Western world yet it is both preventable and reversible.
“What we’ve known for many years is that type 2 diabetes is both preventable and reversible.”
Across 3 episodes, Ray Kelly and Dr Mosley will also shed a light on confronting health disparities and complexities of diabetes risk and prevalence in Australia.
At times they’ll explore confronting issues asking why diabetes death and hospitalisation rates are twice as high in remote areas than in major cities and why Australians are losing a staggering 4400 limbs to diabetes-related amputations every year.
Ray Kelly encouraged families and individual from all backgrounds, especially of Indigenous ancestry, to participate in the program.
“ These Closing the Gap reports tell the same story of failure every year
The danger of this seemingly endless cycle of failure is that it breeds complacency and cynicism, while excusing those in power.
People begin to believe that meaningful progress is impossible and there is nothing governments can do to improve the lives of our people.
The truth is that the existing Closing the Gap framework was doomed to fail when it was designed without the input of Aboriginal and Torres Strait Islander people. We know what will work best for our communities and the Prime Minister even acknowledges in this report that our voice was the missing ingredient from original framework.
The Coalition of Peaks has signed a formal partnership agreement with every Australian government, where decision-making on design, implementation and evaluation of a new Closing the Gap framework will be shared. Through this partnership, the Coalition of Peaks has put forward structural priority reforms to the way governments work with and deliver services to Aboriginal and Torres Strait Islander people.
Governments say they are listening to Aboriginal and Torres Strait Islander people. However, the true test in listening is translating the priority reforms into real, tangible and funded actions that make a difference to Aboriginal and Torres Strait Islander people right across our country.
This historic partnership could be the circuit-breaker that is needed. However, if they view this process as little more than window dressing for the status quo, the cycle of failure evident in today’s report is doomed to continue.”
Pat Turner, CEO of NACCHO and Co-Chair of the Joint Council on Closing the Gap, said that governments need to learn from these failures, not continue to repeat them.
“Every year for the last 12 years we have listened to a disappointing litany of failure – it’s not good enough, Indigenous Australians deserve better.
We are heartened by the developments last year with COAG and the Prime Minister agreeing to a formal partnership with the Coalition of Peaks on the Closing the Gap strategy.
Indigenous involvement and participation is vital – when our peoples are included in the design and delivery of services that impact their lives, the outcomes are far better.
However, now that partnership is in place, Australian governments must commit to urgent funding of Indigenous healthcare and systemic reform.
Preventable diseases continue to take young lives while unrelenting deaths in custody and suicide rates twice that of other Australians continue to shame us all.
As governments reshape the Closing the Gap strategy, we cannot afford for the mistakes of the past to be repeated. “
Close the Gap Campaign co-Chairs, Aboriginal and Torres Strait Islander Social Justice Commissioner June Oscar AO and National Aboriginal and Torres Strait Islander Health Worker Association (NATSIHWA) CEO Karl Briscoe, have called on the government to invest urgently in health equity for Aboriginal and Torres Strait Islander peoples
Download full Close the Gap campaign press release HERE
” There was one glaring omission from the Prime Minister’s Closing the Gap speech this week. Housing did not rate a mention. Not a word about action on Aboriginal housing or homelessness.
Housing was not even one of the targets, let alone one we were meeting, but it must be if we are to have any chance of finally closing the gap between Indigenous and non-Indigenous Australians on all the other targets for life expectancy, child mortality, education and jobs.
Aboriginal and Torres Strait Islander people make up 3 per cent of Australia’s population but 20 per cent of the nation’s homeless. Aboriginal people are 2.3 times more likely to experience rental stress and seven times more likely to live in over-crowded conditions than other Australians.”
“For the first time ever, there is a commitment from all Australian governments, through COAG, to work with Aboriginal leaders through the peak bodies of Aboriginal organisations to negotiate key strategies and headline indicators that will make a difference.
So long as the negotiations continue in good faith and we stay the course together this should lead to a greater rate of improvement in coming years. Of this I am sure.
There is a commitment to supporting Aboriginal people by giving priority to our own community controlled organisations to deliver the services and programs that will make a difference in our communities while at the same time ensuring mainstream services better meet our needs”
Donna Ah Chee, Chief Executive Officer of the Central Australian Aboriginal Congress : Read full Report Part 1 below.
“Today is another day we reflect on the Federal Government’s inability to meet the Closing the Gap targets.
This report clearly shows that the gap will continue to widen if reforms aren’t translated into tangible, fully funded actions that deliver real benefits to Aboriginal and Torres Strait Islander people throughout the country.
The report reveals that progress against the majority of Closing the Gap targets is still not on track. The gap in mortality rates between Aboriginal and Torres Strait Islander people and non-Indigenous
Australians increased last year and there are very worrying signs on infant mortality.
The Federal Government needs to commit to funding solutions to end over-imprisonment of Aboriginal and Torres Strait Islander people and they must be implemented alongside other areas of disadvantage in the Closing the Gap strategy – health, education, family violence, employment, housing – in order to create real change for future generations.”
Cheryl Axleby, Co-Chair of NATSILS.
“We are deeply concerned about the Federal Government’s decision to not continue funding for remote Indigenous housing. Access to safe and affordable housing is essential to Closing the Gap,”
” SARRAH welcomes the bipartisan approach by Parliamentarians who committed to work genuinely and collaboratively with Aboriginal and Torres Strait Islander leaders.
The potential contribution of Aboriginal and Torres Strait Islander Australians is far greater than has been acknowledged or supported to date.
There are many organisations working hard to close the gap, such as Aboriginal community controlled health organisations right across Australia, and Indigenous Allied Health Australia, the national Aboriginal and Torres Strait Islander peak allied health body.
Governments, through COAG, working with the Aboriginal and Torres Strait Islander Coalition of Peaks have the opportunity to reset the trajectory.”
“ Many of our communities are affected by a range of adverse experiences from poverty, through to violence, drug and alcohol issues and homelessness.
Without an opportunity to heal from the resultant trauma, its impact can deeply affect children’s brain development causing life-long challenges to the way they function in the world.
It is experienced within our families and communities and from one generation to the next.
We need urgent action to support better outcomes and opportunities for our children.”
“Mr Morrison will keep failing First Nations peoples and this country until a genuine commitment to self-determination is at the heart of closing the gap.
The Prime Minister’s same old “welfare” rhetoric indicates that the Government really hasn’t got it. While they say they are committed to the COAG co-design process the PM ignores the point that it is his Government continuing to drive discriminatory programs such as the Cashless Debit Card, the CDP program, ParentsNext and who are failing to address the important social determinants of health and wellbeing.
There are a few things this Government needs to do before they just “get people into jobs”, like invest in the social determinants of health and wellbeing and a housing first approach.”
Australian Greens spokesperson on First Nations peoples issues Senator Rachel Siewert
” Australia’s efforts to close the gap are seemingly stuck in a holding pattern.
Though Prime Minister Scott Morrison has hailed the beginning of a ‘new era’ of improving the health and life expectancy of Aboriginal and Torres Strait Islander people in the launch of the 12th Closing the Gap report, the results are all but unchanged.”
Part 1 : Donna Ah Chee, Chief Executive Officer of the Central Australian Aboriginal Congress
Continued
“It’s also important to recognise that there has been progress here in Central Australia both over the longer term and more recently. Since 1973, the number of Aboriginal babies dying in their first year of life has reduced from 250 to 10 per 1000 babies born, and life expectancy has improved on average around 13 years.
As recently as 2019 we have seen significant improvements across multiple areas.
“Alice Springs has experienced a remarkable 40% reduction in alcohol related assaults and a 33% reduction in domestic violence assaults. This is 739 fewer assaults year on year, or 14 fewer assaults per week”.
“There has been a 33% reduction in alcohol related emergency department presentation which is 1617 fewer presentations year on year or a reduction of 31 per week. Corresponding with this, there has been a decline in hospital admissions and, as noted in the MJA recently, ICU admissions. These are dramatic improvements,” she said.
“The proportion of babies born of low birth weight has halved and the rates of childhood anaemia and anaemia in pregnancy have declined markedly.”
“In addition to this the number of young people who reoffend and therefore recycle through youth detention has dropped dramatically.”
“Combining all of these factors, we are closing the gap on early childhood disadvantage and trauma and this will make a big difference in coming years in other health and social outcomes.”
There are however, still many issues to be addressed, especially with the current generation of young people, as too many have already experienced the impacts of domestic violence, trauma and alcohol and other drugs. Unfortunately, this has led to the youth issues experienced now in Alice Springs.
The NT government recently advised Congress that they are implementing strategies that are aimed at making an immediate difference while at the same time we know key strategies that will make a longer-term difference are already in place. New immediate strategies include:
14 additional police undertaking foot patrols and bike patrols in the CBD
Police now taking young people home where it is safe to do so, rather than telling them to go home themselves
The employment of two senior Aboriginal community police officers from remote communities and the recruitment of three others in town and two at Yuendumu
The flexible deployment of the YOREOs to meet peaks in the numbers of young people out at different hours of the night
The much more active deployment of the truancy officers to ensure all young people are going to school.
Access to emergency accommodation options for young people at night
While progress overall is slower than it should be, it is important to acknowledge the successes we are having because of the good work of many dedicated community organisations and government agencies working together in a supportive environment, where governments are adopting evidence based policies.
“ The good news is that the lack of progress in Closing the Gaps can be turned around, but this requires capitalising on the opportunities presented by the COAG partnership and a fundamental shift in the way programs are run.
I am encouraged that First Peoples and government are finally in the one forum where funding and policy can be aligned and jurisdictional and Indigenous responsibilities assigned and monitored – through the Partnership Agreement with the Coalition of Peak Aboriginal and Torres Strait Island Organisations and the Council of Australian Governments(COAG).
This is a historic development, but one which enables but does not necessarily, of itself, guarantee progress.
For actual progress to occur, there needs to be some fundamental shifts in policy and practice.
I suggest the following 7 steps to turn around the efforts to close of the gap “
Professor Ian Ring AO, Hon DSc see full CV part 2 below : Original published ANTAR
Noting the Prime Minister Scott Morrison will deliver his governments Closing the Gap report Wednesday 12 February
Close the Gap, Coalition of Peaks and Closing the Gap what is the difference ?
Close the Gap is a public awareness campaign focused on closing the health gap. It’s run by numerous NGOs, Indigenous health bodies and human rights organisations.
The campaign was formally launched in 2007, after the release of the social justice report by the Aboriginal and Torres Strait Islander social justice commissioner, Dr Tom Calma.
Close the Gap gained support from state and federal governments when the Council of Australian Governments (Coag) set two health aims among their six targets in 2008: achieving health equality within a generation and halving the gap in mortality rates for children under five within a decade.
The Coalition of Peaks is a representative body comprised of around fifty Aboriginal and Torres Strait Islander community controlled peak organisations that have come together to be partners with Australian governments on closing the gap, a policy aimed at improving the lives of Aboriginal and Torres Strait Islander people.
In 2016, Australian governments wanted to refresh the closing the gap policy which had been in place for ten years. During this refresh process, many Aboriginal and Torres Strait Islander organisations told governments that we needed to have a formal say on the design, implementation and evaluation of programs, services and policies that affect us.
In March 2019, the Coalition of Peaks entered an historic formal Partnership Agreement on Closing the Gap with the Council of Australian Governments (COAG) which sets out shared decision making on Closing the Gap.
Closing the Gap is the name given to Coag’s 2008 national strategy to tackle Indigenous inequality, which includes the Indigenous Reform Agreement, a commitment to closing the gap between Indigenous and non-Indigenous Australians within a specific timeframe, with six key targets
” Everyone deserves the right to a healthy future and the opportunities this affords.
However, many of Australia’s First Peoples are denied the same access to healthcare that non-Indigenous Australians take for granted.
Despite a decade of Government promises the gap in health and life expectancy between Aboriginal and Torres Strait Islander peoples and other Australians is widening.
The Close the Gap Coalition — a grouping of Indigenous and non-Indigenous health and community organisations — together with nearly 200,000 Australians are calling on governments to take real, measurable action to achieve Indigenous health equality by 2030.”
Ian Ring suggests the following 7 steps to turn around the efforts to close of the gap
1.Target Setting
Firstly, target setting is not simply a process of setting out what results would be desirable but needs to take into account what actual services and resources would be required to achieve the targets – and how long it would take to both measure and achieve them. Targeting and budgeting must go hand in hand, and targeting without budgeting is simply a recipe for failure and disappointment.
2.Needs-Based Funding
Secondly, it is a cardinal principle behind government social policy that service provision should be related to need. For example, no one questions the fact that far more is spent on health care for the elderly than on the young who enjoy much better health.
However, while in broad terms the level of need for health care in Aboriginal and Torres Strait Islander people, based on the Burden of Disease studies is approximately 2.3 times higher than for the rest of the population, though the jurisdictions spend $2 approximately pc (87% of needs based requirements) on health for every $1 spent on the rest of the population, the Commonwealth only spends $1.21pc on Aboriginal and Torres Strait Islander people for every $1 spent on the rest of the population (barely half [53%] of the needs based requirements).
This is particularly important as the Commonwealth is largely responsible for the out-of-hospital services required to bring down preventable admissions and deaths. It is utopian and unrealistic to believe that gaps can be closed by spending relatively less on people with worse health.
This is not a plea for some kind of special deal for First Peoples but rather for a level of expenditure that anyone else of the population with equivalent need would receive.
Funds are required to address market failure, particularly with the underuse of Commonwealth funding schemes (MBS/PBS) and to fill current service gaps with services that work and particularly, services designed by and for Aboriginal people (ACCHS). Similar principles apply to other areas of government policy and service provision eg housing, education, welfare etc.
3.Focus on Services
Thirdly, there seems to be a widespread belief that targets are somehow self-fulfilling, that all that is required is to set targets, measure them and that somehow or other the targets can be achieved.
This is of course nonsense, but indicative of the need for skills training in health planning and related fields (see below). Having set targets, it is absolutely necessary to consider what services are required to achieve the targets, what services are available and what services are missing, and the investment required to fill the service gaps. For services that are available, it is fundamentally important to have evaluation as a mandatory routine to see if the services are accessible, and effective – and if not, why not, and then take the necessary management decisions to improve service delivery (see management below).
4.Training
There is clear evidence across a range of fields (health, education, housing, justice etc) that significant progress is possible using methods that are tried and tested.
But Aboriginal health and related issues are not so simple that anyone can tackle them effectively. They are complex and require considerable skills and service delivery experience for effectiveness.
Throwing staff in at the deep end is inefficient, and not fair either to the staff or to Indigenous people. Health planning, for example, is a defined skill and requires specific training and a manifest lack of planning skills lies at the heart of suboptimal service delivery A fundamental understanding of culture is an absolute necessity as is a very solid grounding in service delivery experience. The need for training extends right across the board and applies to clinicians, health service administrators and public servants.
For each individual the question needs to be asked – what training does this person require in order to fulfil their role with maximum effectiveness? It is time for amateur hour to come to an end and for the development and implementation of a National Training Plan to ensure all involved are adequately equipped for their individual roles – and it will not be possible to adequately realise on the investments involved in Indigenous service provision without appropriate staff training.
5.Management
For many, the concept of management is little better than sitting around and hoping that somehow, miraculously, next year’s results will be better. That is not how Gaps are Closed.
A formal, integrated, multilayered management system is required – supported by appropriate information and evaluation systems.
At the service delivery level there needs to be formal review processes, at least mid-year and annually, to consider both process and outcome measures in relation to the specified targets – with a timeframe that is based on trajectories which set out what results can and should be expected at different points of time.These measures need to be replicated at regional and jurisdictional levels in the context of a wider consideration of staffing, training and resourcing issues. At the national level the focus needs to be on both resourcing and policy issues. At every level, the question needs to be how well are we doing, and what needs to be done to achieve better results – and then to take the appropriate management decisions required to achieve the targets.
6.Continuous Quality Improvement
There is incontrovertible evidence that sizeable and rapid gains are possible in both chronic disease and in the health of mothers and babies. But those gains require high quality services and are not achieved without proper systems for measuring, monitoring and improving the quality of services.
Such approaches are standard throughout industry and need to be a formal component of health service delivery and other areas of social policy. CQI processes have been used for some services but need to be mandated and funded as a national requirement so that everyone involved in Indigenous service provision lives and breathes service quality enhancement and participates in the formal processes involved.
7.Learning from national and international experience
There are many fine examples of Indigenous Health service delivery – and some of the best health services in the country are provided by the Aboriginal Community Controlled Health Services.
The Institute of Urban Indigenous Health in South-East QLD (IUIH) is an outstanding example of how to integrate Primary Health Care services, both Indigenous and mainstream, under Aboriginal and Torres Strait Islander leadership. in achieving the desired results in term of Closing the Gap.
It is just one of a number of examples around the country, but such examples need to become systematic, comprehensive and national throughout Australia. There are similar examples of services for mothers and babies which reduce low birth weight rates and lower perinatal mortality. In the important field of chronic disease, it has been demonstrated that systematic application of current knowledge can achieve dramatic reductions in mortality in short time periods. We know what to do, have shown that impressive results can be achieved but nationally, progress in both child health and chronic disease falls a long way short of what is required. There needs to be formal support programs, to replicate successful models of these services, adapted as needed to meet local needs, right throughout Australia.
Similarly, successful programs like Housing for Health, developed for the Commonwealth (and subsequently dropped [!] but picked up by the NSW government) have improved housing and consequently health, and doing so by training and employing local Aboriginal people. It beggars belief that programs of such obvious worth are not universally delivered across Australia, and that needs to be rectified as a matter of urgency.
In other fields, child development and justice reinvestment programs have been shown to be effective and cost effective, both in Australia and overseas, but implemented on a piecemeal and patchy basis in Australia. That cannot continue.
Government budgets tend to focus on outlays rather than investment – and more importantly, return on investment. This is inefficient and, in the end, wasteful. The recent NZ Wellbeing budget shows a different approach and needs careful consideration.
Conclusion
None of the measures above are radical or untested or impossible to implement. Indeed, they are standard throughout much of the world. Not implementing them has proved costly in terms of poor results and suboptimal returns on investment.
The time for amateurism is over and Australia needs to lift its game. and these standard measures, under First Peoples leadership, and in the context of the COAG partnership, we can make a significant contribution to the achievement of Australia’s national Goals to Close the Gap.
The Gaps can and should be closed – but not by fine words and good intentions.
Much progress is possible in relatively short periods of time and Australia could and should be the world leader in Indigenous affairs.
Part 2 Professor Ian Ring AO, Hon DSc
Professor Ian Ring AO, Hon DSc is a Professorial Visiting Fellow, School of Public Health and Community Medicine, University of New South Wales, Adjunct Professor in the School of Indigenous Australian Studies, James Cook University and Honorary Professorial Fellow in the Research and Innovation Division at Wollongong University.
He was previously Head of the School of Public Health and Tropical Medicine at James Cook University, Principal Medical Epidemiologist and Executive Director, Health Information Branch, at Queensland Health, and Foundation Director of the Australian Primary Health Care Research Institute at the Australian National University.
He has been a Member of the Board of the Australian Institute of Health, Member of the Council of the Public Health Association and the Australian Epidemiological Association.
He is an Expert Advisor to the Close the Gap Steering Committee and a member of the International Indigenous Health Measurement Group, Aboriginal and Torres Strait Islander Demographic Statistics Expert Advisory Group, Scientific Reference Group Indigenous Clearinghouse, Australian Indigenous HealthInfoNet Advisory Board, and AMA Taskforce on Indigenous Health.
“When kids eat a healthy diet with a wide variety of fruit and vegetables in that diet, they actually perform better in the classroom.
They’re going to have better stamina with their work, and at the end of the day it means we’ll get better learning results which will impact on them in the long term.”
Marlborough Primary School principal
“ We know that fuelling children with the appropriate foods helps support their growth and development.
But there is a growing body of research showing that what children eat can affect not only their physical health but also their mood, mental health and learning.
The research suggests that eating a healthy and nutritious diet can improve mental health¹, enhance cognitive skills like concentration and memory²‚³ and improve academic performance⁴.
In fact, young people that have the unhealthiest diets are nearly 80% more likely to have depression than those with the healthiest diets
Continued Part 1 Below
” Aboriginal and Torres Strait Islander people suffer increased risk of chronic disease such as type 2 diabetes and heart disease.
Eating healthy food and being physically active lowers your risk of getting kidney disease and type 2 diabetes, and of dying young from heart disease and some cancers.
Being a healthy weight can also makes it easier for you to keep up with your family and look after the kids, nieces, nephews and grandkids. “
Continued Part 2 Below
Part 1
Children should be eating plenty of nutritious, minimally processed foods from the five food groups:
fruit
vegetables and legumes/beans
grains (cereal foods)
lean meat and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans
milk, yoghurt, cheese and/or their alternatives.
Consuming too many nutritionally-poor foods and drinks that are high in added fats, sugars and salt, such as lollies, chips and fried foods has been connected to emotional and behavioural problems in children and adolescents⁵.
In fact, young people that have the unhealthiest diets are nearly 80% more likely to have depression than those with the healthiest diets¹.
Children learn from their parents and carers. If you want your children to eat well, set a good example. If you help them form healthy eating habits early, they’re more likely to stick with them for life.
So here are some good habits to start them on the right path.
Eat with your kids, as a family, without the distraction of the television. Children benefit from routines, so try to eat meals at regular times.
Make sure your kids eat breakfast too – it’s a good source of energy and nutrients to help them start the day. Good choices are high-fibre, low-sugar cereals or wholegrain toast. It’s also a good idea to prepare healthy snacks in advance for them to eat in between meals.
Encourage children to drink water or milk rather than soft drinks, cordial, sports drinks or fruit juice drinks – don’t keep these in the fridge or pantry.
Children over the age of two years can be given reduced fat milk, but children under the age of two years should be given full cream milk.
Why are schools an important place to make changes?
Schools can play a key role in influencing healthy eating habits, as students can consume on average 37% of their energy intake for the day during school hours alone!6
A New South Wales survey found that up to 72% of primary school students purchase foods and drinks from the canteen at least once a week7. Also, in Victoria, while around three-quarters (77%) of children meet the guidelines for recommended daily serves of fruit, only one in 25 (4%) meet the guidelines for recommended daily serves of vegetables8; and discretionary foods account for nearly 40 per cent of energy intake for Victorian children9.
It’s never too late to encourage healthier eating habits – childhood and adolescence is a key time to build lifelong habits and learn how to enjoy healthy eating.
Get started today
You can start to improve students’ learning outcomes and mental wellbeing by promoting healthy eating throughout your school environment.
Aboriginal and Torres Strait Islander people suffer increased risk of chronic disease such as type 2 diabetes and heart disease.
Eating healthy food and being physically active lowers your risk of getting kidney disease and type 2 diabetes, and of dying young from heart disease and some cancers.
Being a healthy weight can also makes it easier for you to keep up with your family and look after the kids, nieces, nephews and grandkids.
Aboriginal and Torres Strait Islander people may find it useful to chose store foods that are most like traditional animal and plant bush foods – that is, low in saturated fat, added sugar and salt – and use traditional bush foods whenever possible.
The Healthy Weight Guide provides information about maintaining and achieving a healthy weight.
The national Live Longer! Local Community Campaigns Grants Program supports Indigenous communities to help their people to work towards and maintain healthy weights and lifestyles. For more information, see Live Longer!.
Part 3 Parents may not always realise that their children are not a healthy weight.
If you think your child is underweight, the following information will not apply to your situation and you should seek advice from a health professional for an assessment.
If you think your child is overweight you should see your health professional for an assessment. However, if you’re not sure whether your child is overweight, see if you recognise some of the signs below. If you are still not sure, see your health professional for advice.
Overweight children may experience some or all of the following:
Having to wear clothes that are too big for their age
Having rolls or skin folds around the waist
Snoring when they sleep
Saying they get teased about their weight
Difficulty participating in some physically active games and activities
Avoiding taking part in games at school
Avoiding going out with other children
Signs that a child is at risk of becoming overweight, if they are not already, include:
Eating lots of foods high in saturated fats such as pies, pasties, sausage rolls, hot chips, potato crisps and other snacks, and cakes, biscuits and high-sugar muesli bars
Eating take away or fast food meals more than once a week
Eating lots of foods high in added sugar such as cakes, biscuits, muffins, ice-cream and deserts
Drinking sugar-sweetened soft drinks, sports drinks or cordials
Eating lots of snacks high in salt and fat such as hot chips, potato crisps and other similar snacks
Skipping meals, including breakfast, regularly
Watching TV and/or playing video games or on social networks for more than two hours each day
1 Jacka FN, et al. Associations between diet quality and depressed mood in adolescents: results from the Australian Healthy Neighbourhoods Study. Aust N Z J Psychiatry. 2010 May;44(5):435-42. https://doi.org/10.3109/00048670903571598571598 2 Gómez-Pinilla, F. (2008). Brain foods: The effects of nutrients on brain function. Nature Reviews Neuroscience, 9(7), 568-578. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2805706/ 3 Bellisle, F. (2004). Effects of diet on behaviour and cognition in children. British Journal of Nutrition, 92(2), S227–S232 4 Burrows, T., Goldman, S., Pursey, K., Lim, R. (2017) Is there an association between dietary intake and academic achievement: a systematic review. J Hum Nutr Diet. 30, 117– 140 doi: 10.1111/jhn.12407. https://onlinelibrary.wiley.com/doi/pdf/10.1111/jhn.12407 5 Jacka FN, Kremer PJ, Berk M, de Silva-Sanigorski AM, Moodie M, Leslie ER, et al. (2011) A Prospective Study of Diet Quality and Mental Health in Adolescents. PLoS ONE 6(9): e24805. https://doi.org/10.1371/journal.pone.0024805 6 Bell AC, Swinburn BA. What are the key food groups to target for preventing obesity and improving nutrition in schools? Eur J Clin Nutr2004;58:258–63 7 Hardy L, King L, Espinel P, et al. NSW Schools Physical Activity and Nutrition Survey (SPANS) 2010: Full Report (pg 97). Sydney: NSW Ministry of Health, 2011 8 Department of Education and Training 2019, Child Health and Wellbeing Survey – Summary Findings 2017, State Government of Victoria, Melbourne. 9 Department of Health and Human Services 2016, Victoria’s Health; the Chief Health Officer’s report 2014, State Government of Victoria, Melbourne.
“Over the past few weeks I’ve travelled to Queensland and the Northern Territory to listen to Indigenous Australians – I am committed to being the minister for all Indigenous Australians, and want to make sure that all of their voices can be heard loud and clear,”
The best outcomes are achieved when Indigenous Australians are at the centre of decision making.
We know that for too long decision making treated the symptoms rather than the cause.”
Mr Wyatt said when launching the consultation process he wanted a group of individuals “to have the rigorous discussions” The Morrison government has committed $7.3 million for the process.
“I would like to get the opportunity to establish the bodies and the process and look at all the models and how they might work, and then at a future time look at – and this is the government’s role – to look at constitutional enshrinement or whatever,”Calma told the Guardian late last month
Both Calma and Langton support constitutionally enshrining the voice to parliament, but have said they are willing to work with the process to see what can be achieved.
” CEO of National Aboriginal Community Controlled Health Organisation (NACCHO), Pat Turner AM will be instrumental in the discussions and has previously said the long-term solution of Aboriginal and Torres Strait Islander self-determination requires a strong commitment to the Uluru Statement from the Heart. “
The Minister for Indigenous Australians has announced a list of twenty names that will become members of the Senior Advisory Group that will charged with tasked with guiding the Co-Design process towards developing options for an Indigenous voice to government.
The list includes Uluru Statement from the Heart Advocate, Noel Pearson, National Aboriginal Community Controlled Health Organisation (NACCHO) CEO, Pat Turner, and the first international Indigenous netballer, Marcia Ella-Duncan.
Last week, the Minister for Indigenous Australians, Ken Wyatt, announced he would be creating an elite committee that would oversee a co-design process to work towards realising an Indigenous voice to government.
The top committee will be responsible for developing two lower consultation groups at a local and regional, and national level to assist in putting forward models for consideration.
Indigenous Academics Professor Tom Calma and Professor Marcia Langton have been named co-chairs of the Senior Advisory Group and will oversee a committee made up of both Indigenous and non-Indigenous people.
Members include:
Professor Tom Calma AO
Professor Dr Marcia Langton AM
Professor Fr Frank Brennan SJ AO
Professor Peter Buckskin PSM
Ms Josephine Cashman
Ms Marcia Ella-Duncan OAM
Ms Joanne Farrell
Mr Mick Gooda
Mr Chris Kenny
Cr Vonda Malone
Ms June Oscar AO
Ms Alison Page
Mr Noel Pearson
Mr Benson Saulo
Ms Pat Turner AM
Professor Maggie Walter
Mr Tony Wurramarrba
Mr Peter Yu
Dr Galarrwuy Yunupingu AM
The first meeting of the Senior Advisory Group will be held next Wednesday 13 November at Old Parliament House.
As the group prepares to kick off 12 months of consultations, there are some notable inclusions and absences.
Many prominent Indigenous Rights advocates are wary of the co-design process, saying the only meaningful form of recognition is through a constitutionally enshrined advisory body, truth-telling process and Makarratta commission, as called for in the Uluru Statement from the Heart.
CEO of National Aboriginal Community Controlled Health Organisation (NACCHO), Pat Turner AM will be instrumental in the discussions and has previously said the long-term solution of Aboriginal and Torres Strait Islander self-determination requires a strong commitment to the Uluru Statement from the Heart.
Lawyer and activist, Noel Pearson, has been selected for the group, following on from his role in the Expert Panel on Constitutional Recognition of Indigenous Australians and the Referendum Council.
He is one of numerous former panel members to be part of the next consultation process.
Other prominent names in the recognition conversation however have been left out, including Professor Megan Davis, a former member of the Referendum Council, and Thomas Mayor, a vocal advocate of the Uluru Statement from the Heart.
Minister Wyatt has previously described outspoken advocates of the Uluru Statement as ‘influencers’, and claimed he preferred to listen to “grassroots” Indigenous voices.
His list includes representatives from across the country.
Former Aboriginal and Torres Strait Islander Social Justice Commissioner, Mick Gooda and current Social Justice Commissioner, June Oscar are also part of the group.
Representing the next generation will be Benson Saulo, the first Indigenous person to be appointed to the Australian Youth Representative to the United Nations and 2014 NAIDOC Youth of the Year.
Sky News political commentator, Chris Kenny was also appointed to the committee.
Members from remote communities include Eastern Arnhem Land leader, Dr Galarrwuy Yunupingu AM and Yawuru man from Broome, Peter Yu.
Mr Wyatt said the group will ensure that all Indigenous people are heard.
“It will be a historic occasion that will mark a shift in the way government and Indigenous Australians work in partnership to shift the pendulum and advance positive outcomes for Aboriginal and Torres Strait Islander peoples,” he said.
“Australians living in remote and regional areas are dying preventable deaths from treatable conditions because of a lack of access to health services.
The damning assessment is contained in a new Australian Institute of Health and Welfare report on rural and remote health, which finds that those in the bush rely heavily on general practitioners to provide primary healthcare services in the absence of specialist doctors.
But patients most in need of GPs often can’t access them, with those in remote areas six times as likely as those in metropolitan centres to report they had no access to one.”
” Aboriginal and Torres Strait Islander people are more likely to have higher rates of chronic conditions, hospitalisations and poorer health outcomes than non-Indigenous Australians
The differences in health outcomes in Remote and Very remote areas may be due to the characteristics of these populations.
The proportion of the population that is Indigenous, is much higher in more remote areas
However, more Indigenous Australians live in Major cities and Inner regional areas (61% of Indigenous Australians) compared with Remote and Very remote areas (19%) “
The AIHW report finds people in remote areas die five years before their city counterparts, with a life expectancy of 76 years.
More than 70 per cent of those living in regional areas are overweight or obese, less than one in 10 eat the recommended number of serves of vegetables per day, and one-quarter have high blood pressure or mental health problems.
Rural Australians are dying of diabetes at much higher rates than city dwellers, and many cancers go undetected because of a lack of access to screening programs.
“The rate of potentially avoidable deaths increased as remoteness increased,” the report says. “These are deaths among people aged 75 and under from conditions considered potentially preventable through individualised care, and/or treatment through existing primary or hospital care.”
The Australian College of Rural and Remote Medicine said the situation was a “tragedy”.
“We have a rural health crisis that extends right across from our Aboriginal and Torres Strait Islander people to our rural communities,” said college president Ewen McPhee.
“I think it’s a tragedy that rural communities continue to be neglected.”
In many tiny towns across the country, residents rely on the Royal Flying Doctor Service to provide access to a GP.
Yesterday in Stonehenge in remote central Queensland, doctor Arthur Beggs and nurse Jo Mahony flew in to provide the fortnightly mobile GP service for the town and surrounding areas of about 50 people.
“A lot of people don’t want to bother us unless they are really unwell and that’s really typical of the stoic, outback approach,” Dr Beggs said.
The RFDS has introduced a chronic disease management plan to the town, tracking baseline health measurements and flying specialist allied health practitioners in every few weeks to provide extra services.
Dr Beggs knows the challenges of being a rural GP, but says the difficulties are outweighed by the satisfaction of the work.
“I find rural and remote medicine fascinating and much more fulfilling than I do city-based medicine,” he said.
A recent report published by the Medical Deans of Australia found only 15 per cent of medical students in their final year of study said they were interested in becoming GPs, the lowest figure in five years.
Dr Beggs said attracting GPs to rural and remote areas was key to improving health outcomes in the bush.
“Modern medicine is all about specialties,” he said.
“The specialties can seem a more lucrative and controlled environment than the realms of general practice, which is unfortunate because general practice gives you a much better overview of people and their health.”
Overall, more Australians live in Major cities compared with rural and remote areas
. In 2017, the proportion of Australians by area of remoteness was:
72% in Major cities
18% in Inner regional areas 8.2% in Outer regional areas 1.2% in Remote areas
0.8% in Very remote areas (ABS 2019b).
On average, people living in Remote and very remote areas were younger than those living in Major cities ( gures 1a and 1c).
Australians aged 25–44 were more likely to live in Remote and very remote areas and Major cities compared with Inner regional and outer regional areas. However, a higher proportion of people aged 65 and over lived in Inner regional and outer regional areas and Major cities, compared with Remote and very remote areas ( gures 1a, 1b and 1c).
Rural and remote Australia encompasses many diverse locations and communities and people living in these areas face unique challenges due to their geographic isolation.
Those living outside metropolitan areas often have poorer health outcomes compared with those living in metropolitan areas. For example, data show that people living in rural and remote areas have higher rates of hospitalisations, mortality, injury and poorer access to, and use of, primary health care services, compared with those living in metropolitan areas.
Health inequalities in rural and remote areas may be due to factors, including:
challenges in accessing health care or health professionals, such as specialists social determinants such as income, education and employment opportunities higher rates of risky behaviours such as tobacco smoking and alcohol use
higher rates of occupational and physical risk, for example from farming or mining work and transport-related accidents.
Despite poorer health outcomes for some, the Household, Income and Labour Dynamics in Australia (HILDA) survey found that Australians living in small towns (fewer than 1,000 people) and non-urban areas generally experienced higher levels of life satisfaction compared with those in urban areas (Wilkins 2015).
Rural and remote Australians also report increased community interconnectedness and social cohesion, as well as higher levels of community participation, volunteering and informal support from their communities (Ziersch et al. 2009).
Part 3 National : Closing the Gap / Have your say CTG deadline extended to Friday, 8 November 2019.
The engagements are now in full swing across Australia and this is generating more interest than we had anticipated in our survey on Closing the Gap.
The Coalition of Peaks has had requests from a number of organisations across Australia seeking, some Coalition of Peak members and some governments for more time to promote and complete the survey.
We want to make sure everyone has the opportunity to have their say on what should be included in a new agreement on Closing the Gap so it is agreed to extend the deadline for the survey to Friday, 8 November 2019.
This will help build further understanding and support for the new agreement and will not impact our timeframes for negotiating with government as we were advised at the most recent Partnership Working Group meeting that COAG will not meet until early 2020.
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:
” Every which way you look at renal disease in Aboriginal people, the only solutions that will work in the long term are those that are Aboriginal–led, culturally responsive, located in Aboriginal organisations and evaluated through an Aboriginal lens.
As I have described below, Danila Dilba and KAMS show you the proven capacity of community control to deliver results and accelerate outcomes for people with chronic renal disease.
Both services have people sharing their experiences at this conference. Keep an eye out for their presentations.
To our non-Indigenous supporters in the audience today, I believe these examples about HOW we want to work together will be inspiring. Please expand your discussions during the conference with a positive acknowledgement of community control, and the rights we have as Aboriginal and Torres Strait Islander peoples to shape our own destiny, to partner with you as equals in service delivery, and to be accountable. ”
Before I begin, I acknowledge the Arrernte people and their country on which we meet today. As many of you may know, I am back home where I was born and feeling very much re-energised by the country that knows me so well, my family and friends.
This conference brings together both community and health care sectors. A hugely diverse audience! Your efforts at this conference will help shape a five-year National Indigenous Kidney Transplantation Strategy to be provided to the Commonwealth in 2020.
With this conference mandate, I hope you will permit me to reflect on the WHY, the HOW and the WHEN of what we are all trying to achieve together.
The WHY is both personal and professional for me.
At the time of his death in 2000 from renal complications, one of my uncles had been the longest living Australian kidney transplant recipient.
And my uncle had been many other ‘firsts’ in his life. For example:
The first Aboriginal person to graduate with a university degree
The first Aboriginal person to play soccer at elite level
and
The first Aboriginal person to be the permanent head of an Australian government department.
My uncle’s name? Charlie Perkins.
His transplant in 1972 – the year he arrived in Canberra for the Tent Embassy – gave my uncle another 28 years of life.
Instead of dying at 36 years of age, he died nearly three decades later at 64.
Imagine if his life had been cut short at 36, which is what would have happened without his renal transplant.
In the words of then Senator Aiden Ridgeway in the Senate chamber in October 2000 about my uncle: “we would not have had his contribution to the life of the nation”.
Dying in his mid-thirties would have been a tragic loss for the country. BUT, it would ALSO have been a tragic personal loss for uncle’s family, including me, and his communities. It would have robbed us of someone we loved far too soon.
Every Aboriginal and Torres Strait Islander person whose life you save is just as important to their family and community as my uncle was to me and mine.
While each one may not have the same national profile as Charlie Perkins, each person has a life with meaning and importance.
The old man you treated last week could be a respected cultural boss, a law man, an esteemed knowledge holder in his own community.
The young woman you treat next week could be on her own journey to become a healer, an artist or elder in her own right, as her community ordains.
The next 20 year-old your efforts engage in renal health could be Australia’s first Aboriginal Prime Minister, or the Chancellor of Australia’s first Indigenous university or our 1000th Aboriginal doctor.
You never know. You must take the long view.
Every premature death from preventable renal disease inflicts a shortfall in community capacity and resilience: now and in the future.
Every funeral adds to our intergenerational trauma, our collective loss and our … exhaustion! We have plenty of reserves — history shows my people always manage to bounce back. BUT the preventable toll of chronic renal disease must stop.
So there it is. The WHY is huge!
Because of this WHY, let me now share a few ideas about HOW.
My first example comes from Danila Dilba Health Service in Darwin.
Data points taken over a ten-year period provided Danila Dilba with unique insights about the management and disease trajectory of people with chronic renal disease before and after the appointment of a Renal Case Manager to their team. Creating this Renal Case Manager position specifically aimed to delay progression of their clients to end-stage kidney disease.
Danila Dilba recruited this new position in early 2008. With this new role, all members of the primary healthcare team were to be supported through the provision of systematic patient monitoring, and access to the latest advice about evidence-based practice for very complex clinical challenges. As a learning organization, Danila Dilba also committed to an independent evaluation of these service changes.
Before this new role, there were clear gaps in care that needed improving. For example:
Documentation in the electronic clinical record system. Only 60% of patients were identified with their diagnosis.
Screening of ‘at risk’ patients was very low. Although there were over 500 patients with diabetes for example, few of these had been screened for chronic renal disease.
There was underuse of the GP management plan. Only 63% of patients had a current plan. Only 14% of these contained self-management goals. Only 26% contained clinical goals.
Using the ten-year data, this independent evaluation documented convincing improvements. The evaluation showed that Danila Dilba increased screening and monitoring of people under their care with Stage 3 to 5 chronic renal disease.
Prompt access to expert knowledge at the tertiary level also increased the organisation’s competence to recognise and effectively manage patients with chronic renal disease and associated complex comorbidities.
BUT the risk of tertiary renal services taking over the management of people to the exclusion of their other health priorities was avoided.
There was a significant increase in the timely identification of people in Stage 3 rather than the later, more difficult stages of chronic renal disease. In fact, the patient numbers with Stage 3 grew from fifteen to 101 patients. The growth in the number of people in Stages 4 and 5 was less dramatic in absolute numbers, but a positive improvement was shown. There was an increase in clinic visits for people with more advanced disease and, overall, improved management of risk factors.
As a result of this initiative, those patients with both renal disease and diabetes were better managed in terms of meeting agreed evidence-based targets for diabetes control.
At Danila Dilba, the proportion of patients meeting specific clinical targets for their care has sat above 90% consistently since 2012. Indeed, management of patients with diabetes has been above average since these data audits commenced. There was a very welcome stabilization of diabetes control for those with Stage 5 renal disease. This is fantastic for the patient’s wellbeing.
Of course, you’ll also be asking whether this increased service output delayed progression of chronic renal disease!
Before the program, 50% of patients ended up with Stage 5 within two and half years of identification. After the program, progression had slowed down dramatically. Rather than two and half years, the time it took to progress had extended out to four years. This represents a significant delay in disease progression. I find these results very positive. In my mind, the rate of progression seems to have been nearly halved. My congratulations to the team.
Overall, this experience has helped shift Danila Dilba to a ‘systems approach’. Their new service design, which also takes services close to home, has increased client access and increased client numbers. This is what community-controlled primary health care is all about. Screening for chronic renal disease is embedded in annual health checks. Anyone with acute kidney injury is managed with clinical precision, until their kidney function returns to usual. Since 2014, there has also been a doubling of people with diabetes, so Danila Dilba staff are managing much more complexity.
As a result of these initiatives, those patients with both renal disease and diabetes are better managed in terms of meeting agreed evidence-based targets for diabetes control. The evidence is convincing. Danila Dilba’s national KPIs are either AT or VERY CLOSE to their 2023 targets.
At Danila Dilba, there is a careful balance between ‘siloed’ technical expertise held by those with super-speciality knowledge about chronic kidney disease, and the need for care that looks at the whole person. As Dr Sarah Giles has said “We’re not managing numbers, we are caring for people”. Danila Dilba is preventing disease onset through effective risk factor management AND preparing people with serious renal disease and their families for choices, for a planned transition to dialysis.
I learned from the Transplant Society’s Performance Report that Aboriginal Australians are less likely than other Australians to receive a kidney transplant primarily because they are less likely to be put on the waiting list. The need for culturally competent pre-transplant education is indisputable. What Danila Dilba shows is that this education cannot happen out-of-the-blue without an existing relationship between the person, their family AND a health service they trust. Expanding that waiting list is a clear role for community-controlled primary health care in concert with their tertiary service colleagues.
The second community-controlled example I’d like to share with you today is from the Kimberley region.
There, the Kimberley Aboriginal Medical Services known as KAMS has taken a pioneering step inbecoming the first aboriginal community controlled renal healthcare service in Australia. And quite possibly in the world. This service is known as Kimberley Renal Services, or KRS, a wholly owned subsidiary of KAMS. By running KRS itself, KAMS ensures a culturally appropriate renal healthcare service is available for Aboriginal people with chronic renal disease close to home.
There are 124 people currently receiving lifesaving haemodialysis treatment cared for by KRS. KRS provides renal healthcare services within four renal health centres. These are located in the towns of Broome, Derby, Fitzroy Crossing and Kununurra. Another 18 patients have chosen Home Therapy. But there is a very large number of Kimberley people waiting in Perth to be able to come back home for dialysis. Perth is a long way from country.
After many years frustrated by a model that wasn’t working for communities, KAMS secured significant funding for this service innovation which they have designed with absolute attention to cultural safety and clinical outcomes.
KRS has ensured a multi-disciplinary team approach is available to support people throughout their renal healthcare journey. Access to the renal health centres is provided 6 days a week Monday to Saturday all year round. The only days that the service is not available are Sunday’s and Christmas Day.
In designing their own solution, our colleagues in KAMS thought it was important to emphasise health as a priority, not disease. So the decision was made to change from the previous term ‘dialysis units’ to the new term, ‘renal health centres’. Anyone can engage with their renal health centre for advice, information and understanding.
There is a focus on local staff in each of these sites, learning and doing and caring for their families and communities in jobs vital for the community. These local KRS staff include Aboriginal Health Workers, Patient Care Assistants, Aboriginal care co-ordinators and Aboriginal nurses. KAMS is committed to Aboriginal employment. Currently, 36% of the staff employed in KRS is Aboriginal. There is an affirmative Aboriginal employment policy and, because KRS is managed by KAMS, cultural values permeate the entire service. No patient is seen without an Aboriginal staff member. All non-Indigenous staff recognise that Aboriginal staff guide their practice.
As a matter of necessity, there are three “renal GPs” in the team. These are qualified GPs credentialed for independent practice who have also gained specific expertise in the nuanced management of chronic renal disease and other medical conditions affecting kidney function. In a region the size of Germany, this works in a shared care model.
KRS has also been designed to conduct scheduled outreach to communities. In doing so, this KRS multidisciplinary team does not cut across primary health care. Indeed, KRS has a shared care model that requires a strong foundation in primary health care to work. This partnership is best when there are common values, clear team arrangements and community control. Clinical medical records are shared. The renal team offers in-service training, both formal and informal, any time they are visiting a location for regular community outreach visits. There can be telephone enquiries about patients at any time.
Another part of this service addresses community engagement and life-saving prevention. There are approximately 2,800 people known to KRS who are in Stages 1 to 3 of chronic renal disease across the region. It is this commitment to prevention that will stem the tide of future incidence.
KAMS is looking outwards and wants to ensure none of these people in Stages 1, 2 or 3 progress to the more critical Stages 4 or 5. Currently, there are 138 people progressing to End Stage Kidney Disease. These patients will require haemodialysis within the next 12 to 18 months. This will more than double the caseload. With this projection, people are asking why the region does not yet have at least one full-time residential nephrologist. Addressing this unresolved aspect of medical workforce planning and distribution nationally is critical to successful chronic disease management, and achieving equity of access to renal replacement therapy that our people deserve.
Having visited the Kimberley last week, I was most impressed by the commitment to evidence-based renal disease management through Australia’s first community-controlled renal healthcare service. Speaking with staff and community, the best outcomes are coming through with community-controlled primary health care. Indeed, this KAMS model can’t work unless there is a strong foundation of community-controlled primary health care.
I learned last week that some of the greatest frustrations occur when primary health care is understaffed, especially when members of the primary health care team are pulled off chronic disease management for a different priority, OR when locum staff don’t handover properly and neglect to check critical pathology results. These “stop-start” dynamics in primary health care are seen in all settings across the country. They compromise shared care models. They are also unsafe for patient care.
For this reason, NACCHO is leading national projects to ensure that core services are fully funded in primary health care and deliver the outcomes our people deserve.
NACCHO supports statements by various governments to transition Aboriginal primary health care to community control. Successful transition of one local primary health care service in East Arnhem from government management to community control achieved a 400% (yes, FOUR hundred percent) increase in episodes of care within five years. This community engaged with an Aboriginal community-controlled primary health care service in a way that increased health checks beyond the national average. More babies were born with healthy weights. You, in the audience, know better than me the importance of healthy human development right from the beginning of conception to ensure healthy kidneys for life!
Every which way you look at renal disease in Aboriginal people, the only solutions that will work in the long term are those that are Aboriginal–led, culturally responsive, located in Aboriginal organisations and evaluated through an Aboriginal lens.
As I have described, Danila Dilba and KAMS show you the proven capacity of community control to deliver results and accelerate outcomes for people with chronic renal disease. Both services have people sharing their experiences at this conference. Keep an eye out for their presentations.
To our non-Indigenous supporters in the audience today, I believe these examples about HOW we want to work together will be inspiring. Please expand your discussions during the conference with a positive acknowledgement of community control, and the rights we have as Aboriginal and Torres Strait Islander peoples to shape our own destiny, to partner with you as equals in service delivery, and to be accountable.
So that covers the WHY and the HOW.
I want to talk about WHEN.
WHEN should we start working differently together?
The answer is right now.
An historic Partnership Agreement on Closing the Gap has been signed between COAG and the national Coalition of Peak Aboriginal and Torres Strait Islander Organisations. Now, for the first time, Aboriginal and Torres Strait Islander people through their peak representatives will share decision making with governments on Closing the Gap.
This Partnership Agreement has created a high-level COAG Joint Council for Indigenous Affairs.
This Joint Council is made up of 22 members. That means a Minister from the Commonwealth Government, a Minister from each State and Territory Governments, and a representative from local government. This makes up ten members.
What about the other twelve?
The Coalition of Aboriginal Peak Bodies has ensured that the majority of members on this Joint Council are Aboriginal or Torres Strait Islander representatives. Chosen by us, in the majority, working for our mobs.
The Joint Council has three reform priorities. These are:
Establishing shared formal decision making between Australian governments and Aboriginal and Torres Strait Islander people at the State/Territory, regional and local level to embed ownership, responsibility and expertise on Closing the Gap.
Building and strengthening Aboriginal and Torres Strait Islander community-controlled organisations to deliver services and programs in priority areas.
Ensuring all mainstream government agencies and institutions undertake systemic and structural transformation to contribute to Closing the Gap.
This commitment to equal partnership through COAG has brought us to the table. There’s no going back.
The Joint Council also agreed to the Coalition of Peaks leading engagements with Aboriginal and Torres Strait Islander people to ensure others can have a say on the National Agreement on Closing the Gap. Surveys are out now and can be submitted anytime by Friday 25 October.
So to close my presentation to you today, a final reflection.
I am mindful that the Bulletin of the World Health Organization recently carried an article stating that kidney disease is ‘THEmost neglected chronic disease’.
….. but neglected by whom?
Certainly NOT by anyone in THIS audience!
I applaud your dedication and your hard work. By being here in Alice Springs, your commitment to better health for Aboriginal and Torres Strait Islander peoples in Australia is visible and much appreciated.
I know this issue is complex and no doubt frustrating. Occasionally, you must feel completely demoralized in your work. The Society’s Performance Report recognizes there is ‘no easy fix’.
But please be strengthened by the WHY, the HOW and the WHEN I have described today.
Working together, we can achieve even more than my uncle ever imagined.
National : Closing the Gap / Have your say CTG deadline extended to Friday, 8 November 2019.
The engagements are now in full swing across Australia and this is generating more interest than we had anticipated in our survey on Closing the Gap.
The Coalition of Peaks has had requests from a number of organisations across Australia seeking, some Coalition of Peak members and some governments for more time to promote and complete the survey.
We want to make sure everyone has the opportunity to have their say on what should be included in a new agreement on Closing the Gap so it is agreed to extend the deadline for the survey to Friday, 8 November 2019.
This will help build further understanding and support for the new agreement and will not impact our timeframes for negotiating with government as we were advised at the most recent Partnership Working Group meeting that COAG will not meet until early 2020.
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:
