National Aboriginal Community Controlled Health Organisation chairman Justin Mohamed said yesterday it was disappointing the focus on Aboriginal affairs so far had been on education and economic development with barely a mention of the need to improve indigenous health.
“Addressing Aboriginal education and employment and stimulating economic development are critical issues, but our people must be healthy for them to come to fruition,” Mr Mohamed said at the body’s inaugural National Aboriginal Primary Health Care Summit in Adelaide.
“We still have a massive health gap between Aboriginal and non-Aboriginal Australians, with a life expectancy up to 17 years different.
“We can’t afford to take the focus off improving the health of our people, and many in our communities are waiting to see concrete policies and commitments from all parties in this area.”
Mr Mohamed said NACCHO’s 10-point Investing in Healthy Futures for Generational Change gave a framework for all political parties to work with.
“We have concrete evidence that Aboriginal health in Aboriginal hands is what is really making the difference in achieving better health outcomes for our people,” he said.
He pointed to the improvements in Aboriginal child birth weights, maternal health and management of chronic diseases recorded by the Australian Institute of Health and Welfare in their Healthy for Life Report Card.
“We need to capitalise on these gains,” he said. “We can’t be complacent when it comes to Aboriginal health and we need to see all political parties take it seriously.
Some suggestions for how researchers and health services might do a better job of engaging with Aboriginal patients and communities have come from a research project spanning rural, regional and remote NSW.
The suggestions include taking time to develop trust and relationships (including with community members outside of the health sector), recruiting Aboriginal staff, and engaging patients and communities through art and social media.
The NHMRC-funded Gomeroi gaaynggal program recruits Aboriginal women in early pregnancy and monitors their health and that of their infants throughout pregnancy. It aims to promote the early detection, diagnosis and prevention of diabetes and kidney disease.
Work began on setting up the program in 2006, recognising that many Aboriginal women are deeply mistrustful of mainstream pregnancy-related healthcare services, and this contributes to low uptake of antenatal care.
Sharing some strategies that work for Aboriginal health
Lynsey Brown writes:
Based on their experiences in Walgett (NSW) and other regional, rural and remote Aboriginal communities, Dr Kym Rae and colleagues describe strategies to improve recruitment and retention of Aboriginal people in research and antenatal programs.
The lessons learnt stem from the NHMRC-funded Gomeroi gaaynggal program, which investigates health issues across pregnancy and the post-natal period.
The Gomeroi gaaynggal team also works in partnership with the Aboriginal community and a range of health service providers to deliver an ArtsHealth program that addresses health literacy and service use.
The authors describe key strategies for recruitment and retention that can be applied across diverse regions.
Promoting both ownership and engagement, they note how community consultation must occur across multiple levels. For example, when establishing a health service, it is important to include conversations with not only health professionals but also organisations and individuals working in different areas across a range of social determinants of health (eg, housing, education, justice system), and particularly engaging with local community Elders.
It is this open and trusting dialogue that enables partnerships between researchers, clinicians and communities.
Community consultation is a step towards building trust, which is necessary between researchers and the community, and between research teams and partner organisations. However, trust takes time.
The authors describe prioritising recruitment of Aboriginal staff to enable open discussions, friendships and a supportive mentored environment, which helps this trust and sense of collaboration to develop.
The use of new technologies (in areas with adequate internet connectivity) is also discussed in detail. Social media such as Facebook can be beneficial in establishing connections, maintaining contact, keeping up-to-date with developments, providing opportunity for private emails, and encouraging communication at less cost than a phone call.
The importance of addressing local needs is emphasised, with the authors identifying successful recruitment and retention strategies in different areas.
For regional areas, provision of food and transport vouchers reduces costs for families travelling to health services. Further, Aboriginal staff spend time liaising closely with community members and health services staff.
In rural areas arranging transport and improving local access to services are key strategies. Facebook is also particularly valuable in promoting connection between the program and participants in this space.
Additionally, the authors highlight the benefits of requesting details of three contact people for each participant, to enable connection with families who often change residences.
In the remote region, the key factor is collaboration between the research team and the local Aboriginal Medical Service – with co-located offices and matching uniforms promoting an ongoing partnership.
Despite centres in different locations determining their own approach, it seems the generated strategies are applicable to other health professionals working to close the gap.
• Lynsey Brown is Research Associate, PHC RIS
• Rae K, Weatherall L, Hollebone K, Apen K, McLean M, Blackwell C, et al. (2013). Developing research in partnership with Aboriginal communities – strategies for improving recruitment and retention. Rural and Remote Health 13: 2255. (Online)
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Recently Donna Ah Chee, CEO , Central Australian Aboriginal Congress in Alice Springs , gave a speech at the launch of the Kidney Action Network, examining progress in managing this major health threat to indigenous communities and the work still ahead.
Members of the network who also spoke at the launch Left to right: John Paterson (CEO AMSANT), Donna Ah Chee (CEO Central Australian Aboriginal Congress), Preston Thomas (Deputy Chair of Ngaanyatjarra Health / Director of Western Desert Dialysis), Sarah Brown (CEO Western Desert Dialysis), Andrea Mason (Coordinator, NPY Women’s Council)
The following article is reproduced from our friends at CROAKEY
The report found that Indigenous Australians develop end stage kidney disease (ESKD) at over six times the rate of non-Indigenous Australians and that Indigenous Australians were four times more likely to have chronic kidney disease as a cause of death.
Further, 70% of ESKD cases in indigenous Australians occurred before the age of 60. At the time of that report diabetic neuropathy was the most commonly attributed cause of ESKD present in 60% of cases.
Many thanks to Donna for allowing us to provide the full transcript of her speech below:
The stark reality of the numbers of Aboriginal people on dialysis here in Alice Springs is a constant and real daily reminder of the work that still needs to be done to address Aboriginal health disadvantage and Close the Gap in our life expectancy.
However, at the outset I think it is vital to acknowledge the very real health improvements that are now being seen in the prevention and treatment of chronic illnesses, the very diseases that have created this kidney disease crisis.
Since the beginning of the Primary Health Care Access Program (PHCAP) in the NT back in 2001, there has been a continuing improvement in life expectancy amongst Aboriginal people in the Northern Territory, primarily because of a decline in premature deaths in midlife caused by chronic illnesses.
The NT is currently the only jurisdiction on track to Close the Gap by 2031, if the current trend continues.
There is now much better access to evidence-based treatments, including medicines, than was previously the case. We have many more health professionals on the ground now. This has helped to detect renal disease early and slow its progression.
However it is vital that we do much more in terms of the primaryprevention of renal disease in the first place, and this requires action to prevent the epidemic of obesity and diabetes.
I have just been to a national forum in Canberra on this issue, organised by Diabetes Australia. Congress made four key policy proposals to address the prevention of the obesity and diabetes epidemic:
To re-establish the Primary Health Care Access Program, or PHCAP, so that the expanded primary health care core servicesmodel can be fully funded and so make further improvements in access to primary health care.
To fund the key early childhood programs (ante-natal and for the first three years of childhood) that will help to ensure that all young people have good self-regulation and impulse control and will be more resistant to the development of addictions including fat and sugar
To introduce an alcohol floor price, as cheap alcohol consumption is a major contributor to obesity and the inability to self-manage chronic disease
The introduction of a 20% tax on glucose—especially on the glucose in sugary soft drinks—and fat, with hypothecation of the tax to ensure that the tax is used as a subsidy for fresh fruit and vegetables
We must get much more serious on the prevention of renal disease than we have been up to now.
However, there are now some early signs that for the first time the rate of increase in End Stage Renal Disease may have at least plateaued, as the number of new patients coming on to dialysis in the NT has declined slightly for the first time.
There are many reasons for this, but it is at least partly due to the real improvements that have been made in the NT health system, where a large injection of new resources have been allocated over the last decade in a planned way, according to need.
Unfortunately, in recent years many new resources have been allocated through competitive tendering. This form of funding allocation has been fragmenting the health system, and has the potential to slow down the gains that we have made up to now.
Also, the way that renal dialysis services are being delivered has not been part of this change process. We are largely stuck in the same “centre-based” approach that we have had for decades, with patients being given little option other than to move to Alice Springs and other major centres to go on to dialysis.
It should be acknowledged that there have been efforts to get some dialysis patients home on ‘self-care’ home haemodialysis, but only a very small proportion of our people are currently capable of achieving this.
Congress has advocated for many years for the option of nurse-assisted home-based haemodialysis for all of the reasons outlined in the Central Australian Renal Study, which was completed in 2010.
Congress recognises the work being done by the Western Desert people to help themselves deal with the high levels of kidney problems in their communities. They have led the way in taking initiatives to ensure that there are better options, including nurse-assisted home haemodialysis. Where government have failed to deliver, Aboriginal people have had to try to fill the void with their own funds.
The Western Desert Nganampa Walytja Palyantjaku Tjukaku remote area dialysis services organisation has shown that nurse-assisted home haemodialysis is not only possible, but also very highly valued by the community. This vision needs to be built on by using existing government resources differently; dialysis needs to be decentralised, and provided out bush where people live. It is very likely that this option is not only better but also cheaper. It is not acceptable that in the absence of this option some of our people are choosing to die at home without life-saving dialysis treatment.
There have also been some encouraging signs recently in terms of improved access to renal transplantation for Aboriginal people, with more than 20 transplants in the NT last year. There is still a lot more improvement needed in this area because renal transplantation is the definitive treatment for End Stage Renal Failure, and allows people to live a full, active and healthy life once more. We know that a lot of dedicated people are working hard on this issue.
There has been a lot of work done to bring kidney disease in remote communities to the attention of governments. This work was distilled in the 2010 Central Australian Renal Planning Study.
Congress is very concerned by the refusal of the state and Territory governments to engage with the key recommendations of the Renal Planning Study. This is why we need stronger advocacy and political action. This is why we need the new Kidney Action Network.
There has been a failure to recognise and act on the fact that Alice Springs has to be the hub centre for delivery of services to people in most of the tri-state (NT-SA-WA) cross border desert areas, which rely on Alice as their natural, geographic, social and cultural regional centre.
The failure to provide serious support to the ‘Alice Springs hub centre’ concept means that many patients are still forced to move to Adelaide and Perth, which are too far from their families, communities, social life and cultural necessities.
Congress fully recognises the impact these planning and infrastructure failures have on individuals, their families and their communities. Congress also recognises that tri-state planning is not something that has ever been done well. This is a big challenge for our complex, federated system.
For the sake of the End Stage Renal Patients across the whole of central Australia, we have to get this tri-state planning right and ensure people are provided the right type of renal replacement treatment in their home communities. This must include nurse-assisted home haemodialysis. We also have to address the obesity and diabetes epidemic through effective prevention. We need to all join together through this new Network and make sure all the necessary changes are achieved.
The access of Aboriginal and Torres Strait Islander patients to medications is improving, but more could be done to identify Aboriginal (Indigenous ) patients in general practice, says Jill Dixon, a project manager working in Indigenous health.
Access to primary health care outside the community controlled primary health care services requires patients to be identified and recorded as being of Aboriginal and/or Torres Strait Islander heritage by the general practice to receive access to the closing the gap prescription co-payment relief measure.
General practice also needs to be registered for the Indigenous Health Incentive, Practice Incentive Payment, to be eligible to provide co-payment relief prescriptions
Improving identification of Aboriginal patients in general practice
Our thanks to Jill Dixon for permission to republish:
A recent issue of Australian Doctor (8 November 2012) reported that a significant number of GPs did not know about a scheme that enables eligible Aboriginal and Torres Strait Islander patients to receive free or cheaper PBS medications.
The cost of medications has been identified as a key factor that prevents many Aboriginal and Torres Strait Islander people from obtaining optimum healthcare.
The PBS co-payment measure was introduced in 2010 to address this financial barrier and is a key measure to help close the inequity gap between Aboriginal and Torres Strait Islander people and non-Indigenous people.
The scheme has been successful beyond all projections in providing Indigenous access to vitally needed medications, especially for people with chronic conditions who previously could not afford to fill their prescriptions.
Ninety-six per cent of pharmacies participated in the scheme, dispensing 2.7 million prescriptions during that time.
This translates to a significant increase in the number of Aboriginal and Torres Strait Islander people being better treated for the prevention or management of chronic disease.
However, the report also claims that, while the gap is closing, there is still more to be done in ensuring access to medicines through the PBS Co-payment scheme for all Aboriginal and Torres Strait Islander people.
The most recent data (2008-2009) shows that benefits paid through the PBS scheme were about 74% of the level of expenditures for non-Indigenous people, and total expenditure was only 44% of that for non-Indigenous people.
Surprisingly, the gaps between expenditures for Aboriginal and Torres Strait Islander people and non-Indigenous people are greatest in non-remote areas, because of special provisions for pharmaceutical services for those living in remote and very remote areas.
In addition to cost, another barrier is the extent to which Aboriginal and Torres Strait Islander people access – or are known to access – primary and specialist health care services in the first place.
Mentioned in the above report is the importance of the identification of Aboriginal and Torres Strait Islander patients in those services. After all, how can a GP provide prescriptions under the PBS Co-payment measure if they don’t know that their patient is of Aboriginal and/or Torres Strait Islander origin?
Another recently released report provides some useful information here. The Bettering the Evaluation and Care of Health (BEACH) Report states that Aboriginal and Torres Strait Islander people, who constitute about 2.5% of the total population, were identified at only 1.6% of total GP encounters.
This is only marginally better than findings from 10 years ago, in the 2002-3 BEACH report, which found identification occurring at 1.2% of encounters. See the comparisons here.
We now know that the vast majority of pharmacists actively support the PBS Co-payment Measure.
However, we have no equivalent information on the percentage of general practices that identify the Indigenous status of their patients, thereby helping to start their Aboriginal and Torres Strait Islander patients on the pathway to better health outcomes.
The BEACH data suggest that routine identification in general practices is low, and this would then lead to the generally low uptake of Aboriginal and Torres Strait Islander specific health interventions.
There are many reasons for the low rates of Indigenous identification in general practice.
One is that many GPs and practice staff believe that they don’t have any Aboriginal and/or Torres Strait Islander people amongst their patient group. This is often an assumption based on the location of the practice, or that their patients ‘don’t look Aboriginal’.
Some practice staff believe that Aboriginal and Torres Strait Islander people should be treated just the same as non-Indigenous patients, and so should not receive any special services earmarked for them.
The gap between the health outcomes and life expectancy rates of Aboriginal and Torres Strait Islander people is now well known, and the government Closing the Gap health initiatives are intended to address this shameful discrepancy.
All GPs and practice staff are strongly urged to participate in these measures, starting with routinely identifying the Indigenous status of their patients.
The RACGP Standards for General Practices (4th edition) require general practices seeking accreditation to demonstrate that they ‘routinely record Aboriginal and Torres Strait Islander status in (their) active patient health records’. See the RACGP position statement.
The PBS Co-payment Measure is intended for Aboriginal and Torres Strait Islander people of any age who present with an existing chronic disease or are at risk of chronic disease and in the opinion of the prescriber would experience setbacks in the prevention or ongoing management of chronic disease if they did not take the prescribed medicine and are unlikely to adhere to their medicines regimen without assistance through the Measure. For more information, see here.
It’s now just over 40 years since the first Aboriginal Medical Service, Redfern, opened its doors to provide a community health service for Aboriginal people run by Aboriginal people.
This inspired what is now an incredible network of community controlled health services which is advocating for, and achieving, better health outcomes for Aboriginal and Torres Strait Islander people around Australia.
Despite the odds and many ongoing challenges over those 40 years, the movement has continued to grow and provide quality culturally appropriate services to thousands of our people.
Over the last 12 months, we have had cause to stop and remember where we came from and celebrate the innovative thinking and foresight of those who came together to make the Redfern AMS a reality all those years ago.
In January, we also joined with the Canberra Tent Embassy to celebrate their 40th Anniversary and their significant ongoing contribution to Aboriginal affairs in Australia.
Aside from these significant milestones though, it has been another busy year in Aboriginal community controlled health with many new developments and challenges facing our sector.
At NACCHO, we endorsed our Board of Directors for 2012 and I was honoured to be re-elected to the position of Chairperson for another three years together with our deputy chair Matt Cooke
We also said a reluctant farewell to our CEO Donna Ah Chee in May and we will acknowledge her strong leadership and professionalism she brought to the organisation. The board and myself greatly appreciated Donna’s work with developing the new NACCHO Strategic Plan and the complementary Secretariat Review and restructure.
Following an extensive recruitment process and a strong field of applicants, NACCHO is very pleased to welcome Lisa Briggs as our new CEO. Lisa is a Gunditjmara Aboriginal woman from Victoria and an Aboriginal Health Worker by trade. She has worked in Aboriginal health for the last 25 years predominantly within the Aboriginal Community Controlled Health Sector. She will be a great addition to the NACCHO team.
There have been some other significant changes to our personnel over the last 12 months. Our long standing Public Health Medical Officer Dr Sophie Couzos left to take up a position as an Associate Professor at James Cook University where we know she will continue to influence and be a strong advocate on the ACCH.
Yet we are excited that we have been able to attract two very experienced and influential Aboriginal Doctors to the NACCHO team in Dr Mark Wenitong and, more recently, Dr Ngaire Brown. We are very excited about their future with NACCHO.
LEADERSHIP AND PARTNERSHIPS
While this important recruitment has been occurring, we have been building and strengthening our partnerships with some of the key Aboriginal and non-Aboriginal organisations in the movement..
These critical relationships are ensuring our voice is heard and we continue to play an active role in shaping the direction of Aboriginal health in this country.
We have been able to provide input into Aboriginal health provision and leadership to both government and non-government committees including forums such as the National Heath Leadership Forum of the National Congress of Australia’s First Peoples, Close the Gap Steering Committee, and the Aboriginal and Torres Strait Islander Workforce Working Group.
We have also had some success in having changes made to the consultation around the National Aboriginal and Torres Strait Islander Health Equity Plan and have met with Ministers Plibersek and Snowdon on a regular basis.
In addition, NACCHO has been working to bolster our presence more broadly where it is relevant to improving Aboriginal health by giving keynote addresses, facilitating consultations and workshops across the broader health agenda, producing and lodging submissions, and developing policy at a national and international level.
To name just a few, NACCHO has been involved in the Deadly Choices NRL Cup, NRL Close the Gap Round, ASHM Conference, United Nations Permanent Forum on Indigenous Issues, the National Ear and Hearing Symposium, and the development of Governance Support Frameworks with and for our sector.
As we have discussing in our members meeting over the past few days in next two years NACCHO will continue to focus on three central areas that are consistent with our constitutional objectives.
Strategic Direction 1: Shape the national reform of Aboriginal health.
Strategic Direction 2: Promote and support high performance and best practice models of culturally appropriate and comprehensive primary health care
Strategic Direction 3: Promote research that will build evidence-informed best practice in Aboriginal health policy and service delivery.
For today’s presentation I will talking about my chairperson’s role in direction one shaping the national reform of Aboriginal health in four key areas
National Aboriginal and Torres Strait Islander Health Plan (NATSIHP)
NACCHO have made it our business to attend as many of the consults as possible and ensure our views, recommendations and voice is heard
This our business and together with lobbying and advocacy it is important we participate in the planning process to ensure our voice is heard and tabled at the consultation stages
NACCHO together with our affiliates will be submitting formal submissions placing State, Territory and National views to provide vital ingredients and direction for the governments plans
NACCHO will also be developing our own “blue print “ National Aboriginal Health Plan that will be used for lobbying and comparison with NATSIHP
There are now 61 Medicare Locals established and running across the country – they are here to stay even if there is a change of government next year
Currently we have approximately 20 MLs well engaged with our movement and partnering to deliver services. We need all the MLs to be engaged in real partnerships with us and for them to hear the voice of our sector load and clear.
70% of the services that responded to our recent survey on MLs reported having no formal relationship with the ML in their area – it is crucial that we change this imbalance and get our services on the front foot when dealing with the ML sector
MLs are obviously the current government’s preferred vehicle for delivering on its health reform agenda and we need to be at the table if we want to have a meaningful slice of the pie
If we aren’t active and engaging with these organisations, we will most certainly get left behind. The Partners in Recovery money has flowed to the MLs and all sections of DoHA are now being encouraged by senior bureaucrats to stream their new funding into the Flexible Funding Pools of MLs.
It’s not all bad news though. There are excellent examples from all jurisdictions where our services have taken a lead role in the formation and the governance of MLs and continue to play a key role in their ongoing service delivery and design; we all need to learn from these examples
National Primary Health Care Review
The Department of Health & Ageing – OATSIH, has initiated the National Primary Health Care Funding Review.
OATSIH have engaged KMPG to undertake the national community consultations.
There has been a delay in the role out of the community consultations due to OATSIH needing sign off on their consultation papers. The process outlined to NACCHO states that the consultation papers will be provided to participating organisations two weeks prior to consultations taking place
In May of this year the Deputy chair and I attended the United Nations Permanent Forum in Indigenous Issues in New York where we put forward four recommendations for Agenda Item 4 a: Implementation of the United Nations Declaration on the Rights of Indigenous Peoples: Discussion on the rights of Indigenous Peoples to health
We were very please that recommendations 1 and 3 were accepted and included into the final recommendations of the permanent forum
We recommend that the Permanent Forum:
1. Urge States to investigate and promote models of community control for health, social, legal and other sectors and service providers;
2. Urge States that do not already do so to identify senior Indigenous political and bureaucratic positions and develop capacity building pathways into those positions in health and other portfolios
3. Encourage the World Health Organization (WHO) to revisit the report of the WHO Commission on the Social Determinants of Health to address the cultural determinants of health – such as land, language, ceremony and identity – which are essential to the health and wellbeing of Indigenous Peoples;
4. Requests that States, as part of their reporting activities, provide information on progress towards national& regional& local systems which respect, protect and promote the principles of the right to health.
Over the last 12 months, the Board and I have also made it a priority to get out and see our Affiliates and member services, and wherever possible holding strategic meetings and workshops within organisations.
These visits include the metropolitan and regional districts in the majority of our states and territories, with additional visits planned in November this year.
And finally what are our challenges and opportunities for the future for better health outcomes for our people.
Of course, NACCHO has been continuing to carry the torch for Aboriginal community controlled health through the national reform process and making real inroads into securing better outcomes for our members and communities.
This is a real opportunity to have Aboriginal community controlled health better recognised at the national level and, while there have been some road blocks, we will not give up.
NACCHO has also undertaken a major overhaul of our communications to ensure our stakeholders, members and the broader community are kept as up to date as possible with activities and news affecting our sector and this will be refined in the future to meet your nneds
This has included a higher level of engagement with the traditional media, the launch of a new more user-friendly website, and a greater presence in social media with electronic communiqués and more regular use of Facebook and Twitter.
Internally, we are continuing to focus on governance and working with our Affiliates to ensure we can all shine under the heavy scrutiny of government and registrars.
Overall, it has been a challenging but satisfying year.
As NACCHO continues to deliver, we are sought out more by government and others in the health environment which in itself brings the pressure of more responsibility.
We welcome this challenge and look forward to fulfilling our strategic objectives in the coming 12 months and beyond – shaping health reform, promoting Aboriginal community controlled health care research, and working with our Affiliates and members to ensure better health for our people.
The National Primary Health Care Conference has just wrapped up in Adelaide, and you can get an idea of some of the wide-ranging discussions from the #nphcc Twitter stream.(refer NACCHOAustralia TWITTER)
One of the obvious implications is that we must hope Medicare Locals are skilled in the art and science of setting and implementing priorities, given the smorgasbord of expectations upon them.
Engaging with the Aboriginal community controlled health sector should be a priority, suggests NACCHO’s senior policy officer on health reform, James Lamerton.
In the article below, he has some practical suggestions for how Medicare Locals can go about this.
Medicare Locals and the Aboriginal Community Controlled Health Sector: Where are we? Where are we going?
James Lamerton writes:
At the National Primary Health Care Conference in Adelaide last week the daunting terrain that Medicare Locals are expected to navigate was on display.
Medicare Local CEOs and directors must be tearing their hair or turning to drink after hearing, on the first day, from the Department of Health and Ageing’s David Butt and, on the final day, from the Coalition’s Andrew Southcott; both confirmed that the ML ground will be not only rugged but continually shifting.
One thing, however, does offer the Medicare Locals some degree of certainty and considerable promise; the ongoing presence, in the primary health care environment, of the Aboriginal Community Controlled Health Service (ACCHS) sector that has been providing comprehensive primary health care, based on the social determinants of health thinking, for forty years.
Though Aboriginal health was not a theme at the conference, those representatives of the sector present made it clear that partnerships between Aboriginal Community Controlled Health Service and Medicare Locals are not only possible but highly desirable.
From population health planning, through treatment of chronic conditions to primary mental health care initiatives like the Access to Allied Psychological Services and Partners in Recovery programs, the Aboriginal Community Controlled Health Service sector will be an essential, effective and enduring partner for Medicare Locals.
Examples of high functioning partnerships between Aboriginal Community Controlled Health Services and Medicare Locals abound.
From the Pilbara to the NT; from Brisbane to NSW’s northern rivers and Sydney’s western suburbs, these two crucial players in the primary health care environment have carved out partnerships that are not only rolling out Aboriginal health programs and initiatives together but are also building respect and trust between and within communities.
Meanwhile, many Medicare Local CEOs at the conference, whose organisations do not have formal partnerships with the Aboriginal Community Controlled Health Service within their footprint, showed that they were open to partnering but may need support and guidance.
Tips for engagement
So is there a sure-fire, foolproof recipe that Medicare Local CEOs and their teams can follow that will lead to a successful partnership?
The short answer is no – or, at least, not that I know of – but following are some basic tips that should help.
Research the Aboriginal Community Controlled Health Service in your area and get your head around its operating environment – in other words, show an interest.
Have a look at the constitution, find out who the board members are and where they come from. What programs/projects does the Aboriginal Community Controlled Health Service run, and what is it really good at? What are its pressure points? Maybe in those pressure points there’s a potential partnering opportunity.
Ensure that your local Aboriginal Community Controlled Health Service is a member of your Medicare Local. Why not even look at Aboriginality and experience in the community controlled sector as essential skills for at least one of your directors?
Meet. Get a knock down to the Aboriginal Community Controlled Health Service CEO this week and follow it up, as soon as possible, with a Chair & CEO to Chair & CEO meeting.
Is it possible for the two boards to come together? Not only can this be an excellent trust-building opportunity but it’ll also allow your board members to hear the voice of the Aboriginal community directly (NB be prepared to hear some confronting messages).
Don’t rush it. If you’re building a new relationship or repairing an old one, it’ll most likely take time.
To you and your team, it might seem that things move at a glacial pace within your local Aboriginal Community Controlled Health Service, but this is usually because it is using its community feedback loops to see what people think.
It might be frustrating but this is where the strength of the Aboriginal Community Controlled Health Service lies; see what you can learn from it and extrapolate to your relationships with your traditional and emerging constituencies. (NB: These feedback loops will invariably appear idiosyncratic and puzzlingly opaque: stay cool, they’ve been in place and working pretty well for 60,000 years).
Remember Grandma’s advice: you were born with two ears and one mouth – there’s a reason for that. Active and appreciative listening to a problem will often produce the seeds of a solution. In the Aboriginal Community Controlled Health Service environment, silence not only implies consent but also shows respect.
Start with something small and achievable. We’re not going to close the gap in one fell swoop; agree a project that you can work on together (truly ‘work on together’), even if there are some residual trust issues, and see it through to its conclusion – come hell or high water.
Jointly evaluate it, pick the eyes out of it and carry the characteristics of the relationship into something new. Initial success may prove to be sub-optimal but cast your mind back to when you were learning to swim. That’s right, you started out simply trying not to drown and eventually ended up swimming to Rottnest Island.
Meet 2. Arrange informal but regular meetings between your clinicians and those of the Aboriginal Community Controlled Health Service. It’s amazing what can be shared and learned by both groups in an environment of enquiry.
Own what’s yours but respect what isn’t. Enough said.
The mixed Medicare Local messages coming from Government and Opposition are certainly testing the patience and resolve of the Medicare Local movement; it’s hard to plan when the map is redrawn regularly.
However, the opening whistle’s blown and it’s game-on.
This reform agenda presents us with a potentially epoch-altering opportunity to make serious inroads into comprehensive primary health care and public health thinking based on a ‘rights’ ethos.
To the politicians, the future of Medicare Locals may appear uncertain but the only infallible way for us to predict the future is for us to create it.
More reading: Mark Metherell’s report for Croakey from day one of the conference on the need to shift the funding imbalance between hospitals and primary health care.
Picture above NACCHO Chair, Mr Justin Mohamed, stated it was very important that as respective national peak bodies both NACCHO and AML Alliance need to demonstrate sound leadership and model collaboration if genuine partnership is to be achieved.
Australia’s Medicare Locals and the National Aboriginal Community Controlled Health Organisation (NACCHO) will draw on their respective strengths in primary health care to share in the best way forward to achieve improved health outcomes for Aboriginal and Torres Strait Islander Peoples from the National Health Care Reforms.
In the lead up to a Close the Gap symposium at the National Primary Health Care Conference, AML Alliance Chair, Dr Arn Sprogis said it’s national sessions like these that enable organisations to work cooperatively to develop tangible opportunities for the Close the Gap agenda.
“This session will convene some of the best thinkers and advocates for primary health care in the Aboriginal and Torres Strait Islander health sector to generate the big ideas,” Dr Sprogis said.
“We want the ripple effect: to see good policy lead to better service delivery.
There is a well-earned respect between the two sectors and what they can do for Aboriginal and Torres Strait Islander people, however integrating their systems and thinking is what will expand the opportunities immeasurably.
“We’re determined to pursue the best possible outcomes for Aboriginal and Torres Strait Island Peoples from the National Health Care Reforms,” Dr Sprogis said.
NACCHO Chair, Mr Justin Mohamed, stated it was very important that as respective national peak bodies both NACCHO and AML Alliance need to demonstrate sound leadership and model collaboration if genuine partnership is to be achieved.
“This symposium will allow a full and open discussion of how our sectors view the future and for both to explore and forge new ways of working together as we strive towards true and meaningful partnerships,” Mr. Mohamed added.
“Both sectors independently face challenging futures, so this will be an opportunity for both NACCHO and our members and the AML Alliance to begin to lay stable foundations as we work towards improved collaborative relationships.
Through improved partnerships and Aboriginal leadership there is a real opportunity to produce realistic and achievable policy recommendations to government,” Mr. Mohamed said.
Mr Mohamed encouraged all attendees to approach the symposium as a blank sheet where we can map a way forward that ensures the best possible health outcomes are achieved for our people and their communities.
National Primary Health Care Conference – Healthy Communities, Healthy Nation
From Transition to Action: Integrating Primary Health and Social Care
This is a WA government press release FYI 16 October 2012
The State Government’s biggest single investment into Aboriginal health in Western Australian history had resulted in nearly 100 new services for Aboriginal people and more than 100 new Aboriginal health employees, Health Minister Kim Hames said today.
Under the Council of Australian Government’s (COAG) Closing the Gap National Partnership Agreement, which is now in its final year, the State Government has provided $117.43million to ‘close the gap’ between Aboriginal and non-Aboriginal health.
Dr Hames said about $80 million to date had been directed into new programs and services to improve smoking rates, primary health care and a healthy transition to adulthood for Aboriginal people.
“One of the biggest achievements under the Closing the Gap initiative is the creation of more than 400 new positions – more than 60 per cent in regional and remote areas – to support 98 new Aboriginal services across the State,” he said.
The Minister said the initiative had also provided WA Health with an opportunity to change the way it developed and implemented health services for Aboriginal West Australians.
“The State Government has decentralised its approach and established nine metropolitan and regional Aboriginal Health Planning Forums to foster a genuine partnership between ourselves, non-government and Aboriginal communities at a local level,” he said.
“We have moved away from the ‘one size fits all’ approach by recognising each region and its population is unique in its cultural diversity, and therefore requires a customised approach to planning and delivering services.
“At February 2012, the number of Aboriginal people employed in the WA health sector has risen by 111 to 314 employees.
WA Health developing business plan to potentially continue Closing the Gap initiative past the final year of the initial COAG agreement
Julia V Marley, Carmel Nelson, Vicki O’Donnell and David Atkinson
Objectives: To describe service characteristics of Derby Aboriginal Health Service (DAHS) and document diabetes management activities and intermediate clinical outcomes for Aboriginal patients with type 2 diabetes.
Design, setting and patients: Retrospective audit of records for patients ≥ 15 years old who had a confirmed diagnosis of type 2 diabetes, received primary health care from DAHS for at least 6 continuous months between 1 July 1999 and 30 June 2009, resided in the Derby area and were not on renal replacement therapy.
Main outcome measures: Electronic records of blood pressure (BP), glycated haemoglobin (HbA1c) level, weight, albumin–creatinine ratio, creatinine level or estimated glomerular filtration rate, lipid levels and smoking status during each audit year; and proportions of patients who met clinical targets for HbA1c, BP and cholesterol.
Results: Over the 10 years, the proportion of clinical care activities undertaken according to regional protocols increased significantly, with very high levels recorded in the last 3 years (at least 70% of patients had each activity recorded). There were significant improvements in systolic BP, diastolic BP and cholesterol levels over the 10 years (P < 0.001 for all). In the final year, 69% of patients had at least half their BP measurements ≤ 130/80 mmHg and 83% had median annual cholesterol levels of < 5.5 mmol/L. There were small improvements in HbA1c levels that approached statistical significance (P = 0.05). In the final year, 34% of patients had median annual HbA1c levels of ≤ 7.0%.
Conclusions: This study shows that diabetes monitoring and outcomes can be improved and maintained over a 10-year period in a well supported remote Aboriginal community-controlled health service setting.
International and Australian studies show that well structured approaches to diabetes care can improve short-term and intermediate patient outcomes.1,2 While there are several long-term randomised controlled trials aimed at improving intermediate outcomes in people with diabetes,3,4 there is only one published study on the long-term evaluation of a continuous quality improvement (CQI) program in real-world settings of primary health care.5 Ten years after this CQI program was introduced, there was significant improvement in intermediate outcomes and a reduction in microvascular and macrovascular disease in patients with diabetes in Catalonia.5In Australia, only limited, generally short-term, studies have been published on the effectiveness of real-life service approaches to improving diabetes control. One showed significant improvement in some intermediate outcomes for patients with diabetes in Far North Queensland following the introduction of the “Meriba Zageth for diabetes” plan.6Derby is a small remote Western Australian town with a harsh seasonal climate, 230 km from the regional centre of Broome and 2350 km from Perth tertiary referral centres. The 2006 census rated the Derby–West Kimberley area as the fifth most disadvantaged in Western Australia.7Recruitment and retention of skilled professionals in Derby is a constant challenge, with a number of key local services characterised by high staff turnover. Derby Aboriginal Health Service (DAHS) is an Aboriginal community-controlled health service that was established in 1998. Key characteristics of DAHS include whole-of-service involvement in internal CQI processes, use of electronic patient information and recall systems, and regional support and standardisation of care.We aimed to report on long-term service activity and intermediate clinical outcomes for DAHS Aboriginal and Torres Strait Islander patients with type 2 diabetes.
MethodsThis study covers 10 audit years, from 1 July 1999 to 30 June 2009. It includes Aboriginal and Torres Strait Islander patients seen at DAHS who had type 2 diabetes mellitus, were ≥ 15 years old, received primary care from DAHS for at least 6 continuous months, lived in or near Derby, and were not on renal replacement therapy.The final study population was determined by carrying out a comprehensive retrospective review of paper and electronic records. During review of these records, the date of diagnosis of diabetes for each patient was confirmed as far as possible.
Data extraction and cleaningIn 2007, DAHS staff checked the accuracy of patients’ electronic records against paper records. Results incorrectly recorded or not entered into Project Ferret (Pen Computer Systems), a patient information and recall system, were corrected. From 2007, data entry was monitored more closely. At the end of 2009, data were extracted from Project Ferret and transferred into Excel 2003 (Microsoft). Outliers were identified and data entry errors were corrected. Fewer electronic creatinine results than expected were observed during the audit years 2005–06 and 2006–07 and further corrections, based on paper records, were made. The data were then imported into Stata, version 11 (StataCorp).
Service characteristicsThe major activities and factors likely to have had a direct impact on the quality of care provided to patients with diabetes at DAHS are listed in Box 1.
Quality indicators of diabetes careThe occurrence of activities relating to diabetes management was assessed over the 10 audit years. Measures expected to be recorded at least 6 monthly (blood pressure [BP], glycated haemoglobin [HbA1c] level, weight) were assessed over the last 6 months of each audit year (1 January to 30 June). Measures expected to be recorded annually (albumin–creatinine ratio [ACR], creatinine level or estimated glomerular filtration rate [eGFR], lipid levels, smoking status) were assessed over the full audit year.
Clinical outcome measuresClinical outcome measures were assessed each audit year. Overall median HbA1c and cholesterol levels were determined using medians for individual patients during each audit year. Also, the proportions of patients with median HbA1c and cholesterol levels meeting recommended targets11were determined for each audit year. As the recommended target for BP includes meeting the target for both systolic (≤ 130 mmHg) and diastolic (≤ 80 mmHg) measurements, the proportions of patients with at least half their electronic measurements meeting both targets were determined for each audit year.Patients were classified as having proteinuria and/or kidney disease if they had at least two ACR results > 3.6 mg/mmol without obvious infection, creatinine or eGFR results suggestive of chronic kidney disease,10 and/or were assigned to a proteinuria or chronic kidney disease care plan.
Statistical analysisA non-parametric test for trend across ordered groups was used to assess trend over time.12 Analyses were performed using Stata, version 12 (StataCorp). P < 0.05 was considered statistically significant.
Ethics approvalEthics approval was obtained from the Western Australian Aboriginal Health Information and Ethics Committee and exemption from ethics review was obtained from the Human Research Ethics Committee of the University of Western Australia.
ResultsAfter identifying 517 patients with results suggestive of diabetes, 263 were excluded for not meeting the selection criteria (Box 2). Participants who commenced renal replacement therapy, stopped receiving primary care from DAHS or died were not included after these events occurred.The final study population of 254 patients contributed a total of 1502 patient-years of care. Of this patient population, 107 (42%) were diagnosed after becoming a regular patient at DAHS, 195 (77%) regularly attended DAHS (as determined by the clinic) from when they entered the study until they were excluded or the study finished, 166 (65%) were included in at least 5 audit years, 35 (14%) were included in all 10 years and 45 (18%) were included in both the first and last years. The median age of patients at the time of entering the study was 46 years (range, 15–84 years); 159 patients (63%) were female, 185 (73%) had or developed proteinuria and/or kidney disease, 12 (5%) commenced renal replacement therapy and 41 (16%) died.Service activity for BP, HbA1c, weight, ACR, creatinine level or eGFR, lipid levels and smoking status increased significantly over time (P ≤ 0.002 for trend over 10 years; Box 3). Median annual systolic and diastolic BP values and cholesterol levels decreased significantly over time (P < 0.001 for trend over 10 years; Box 4). The proportion of patients who met currently recommended targets11 for median annual cholesterol and who had at least half their recorded results for BP ≤ 130/80 mmHg also significantly increased over time (P < 0.001 for trend over 10 years; Box 4). Improvements in glycaemic control over time approached statistical significance (P = 0.05 for trend over 10 years; Box 4). In the last year of the study, the proportions of patients who met the old targets of HbA1c < 7.0% and BP < 130/80 mmHg were 33% and 53%, respectively. Previously reported data on care quality indicators and clinical outcome measures relating to diabetes care in other Australian populations are included in Box 3 and Box 4, respectively.1,6,8,9,13–19
DiscussionTo our knowledge, this is the first published Australian study looking at 10 years of diabetes management in primary care at an individual health service. We showed significant and sustained improvements in health monitoring and intermediate outcomes at DAHS.Improved care processes, improved control of BP and prevention of complications that result in hospitalisation have previously been demonstrated in Aboriginal community-controlled health services over short periods when adequate clinical support and appropriate management structures have been provided.2,13The main strength of our study is that we used all recorded results for patients over a 10-year period and analysed clinical outcomes according to clinical targets from current guidelines.11 Comparisons can be made with other studies, but caution is required because of the different methods and clinical targets used. The Australian Primary Care Collaboratives program operates through “waves” of 20–200 practices working together over 18 months,8 while the Audit and Best Practice for Chronic Disease project randomly selected 30 patients with diabetes from each of 62 services and used the most recent value for each patient within 12 months of the audit.9 The currently recommended target for BP is ≤ 130/80 mmHg,11 but previously it was < 130/80 mmHg. In our study, this meant that the proportion of patients with BP complying with target values changed from 53% to 69% in the final year. Similar changes occurred in the Australian National Diabetes Audit and Benchmarking project (54% of patients with BP ≤ 130/80 mmHg in 2009 compared with 38% of patients with BP < 130/80 mmHg in 2006).17,20The change in HbA1c target (< 7.0% to ≤ 7.0%) made less difference in our study (33% v 34% of patients meeting the respective targets in the final year).Limitations of this study included underrecording. In the earlier years, this may have contributed to the trend of improvements over time. As part of the CQI processes at DAHS, staff checked the accuracy of the measures reported in this article and updated electronic records, but some bias due to underrecording in the earlier years is likely. Our data on the duration of diabetes may also be biased because of difficulties in determining when diabetes was diagnosed in patients who were diagnosed at other health services. This study was also limited to data that were available; important outcomes, such as hospital admissions and medication usage, were not recorded electronically and more sophisticated measures relating to quality of life were not collected.
Our results compare well with those of other Australian studies of patients with diabetes. In terms of the intermediate outcome measures that we examined, BP was better controlled than in other Australian studies, including mainstream general practice studies (69% v 28%–54%8,16,17), and cholesterol levels were similar or better (83% v 53%–86%9,15–19). Glycaemic control was near the best reported in Indigenous Australian studies (34% v 22%–32%1,6,9,14,15) but not as good as has been reported in studies of mainstream general practice (37%–57%).8,18,19
Despite the improvements we have shown, there is substantial room for further improvements in clinical outcomes. The focus on preventing or delaying kidney failure in the Kimberley may partly explain why BP control was particularly good in this study. Glycaemic control is considered more difficult to achieve compared with other measures6 and only small improvements in glycaemic control were evident in this study, although even small improvements can be clinically useful. Further investigation is planned to model HbA1c measurements over time for individuals and determine factors that are likely to contribute to individuals attaining and maintaining good glycaemic control.
From 2012, reporting of national key performance indicators (nKPIs) is a requirement for Aboriginal community-controlled health services under the National Indigenous Reform Agreement.21 The nKPIs include the HbA1c and BP measures for patients with diabetes that we included in our study. It is hoped that the use of nKPIs will result in comparable data from Aboriginal health services being produced.
Over the decade covered by our study, a number of policy changes were introduced at a national level which may have had an enabling role for DAHS in chronic disease care for its patients. These include the introduction of Medicare reimbursement for comprehensive Aboriginal and Torres Strait Islander preventive health checks and for chronic disease management planning and follow-up,22 and access to medications at low or no cost for Aboriginal people in remote areas (section 100 of the National Health Act 1953 [Cwlth]).23