NACCHO Aboriginal Health #ClosingtheGap : Pat Turner Convener #CoalitionofPeaks Speech at the National #PHN Conference : Challenging the way Governments and Primary Health Networks work with us

The reform priorities, and that they are being discussed in a COAG forum with Aboriginal and Torres Strait Islander people at the table, as well as the upcoming engagements is a demonstration of how the conversation and approach is changing as a result of the Partnership Agreement on Closing the Gap.  

But this changed approach is not to be just contained to the Partnership Agreement and governments work with the Coalition of Peaks. It is to be applied to all your policy practice and service delivery.

It is a challenge for you (PHN’s) to reconsider how you develop policies and programs with and for Aboriginal and Torres Strait Islander people and communities.

The Partnership Agreement means that:

  • Aboriginal and Torres Strait Islander people are no longer government ‘stakeholders’ but are full partners in the development of policies and programs that impact on us.
  • Primary Health Networks need to develop formal arrangements with us, through our community controlled health organisations, to agree policy and programs, based on our own structures and not your own appointed advisory bodies.
  • The knowledge of Aboriginal and Torres Strait Islander peoples to determine their own solutions must be given primacy in policy and program design and delivery.

I ask that you all consider what the Partnership Agreement will mean to your own Primary Health Network, to the area and team that you work with, to start a conversation with your team members about it, to read further about the work we are doing and set up a time to speak to one of our Coalition of Peaks members to learn more.

The Partnership Agreement presents a significant opportunity for you all to think creatively and with innovation, to not just think about what is possible in the relationship between government and Aboriginal and Torres Strait Islander people, but to be at the forefront of the change.”

Pat Turner NACCHO CEO speaking at the PHN NATIONAL FORUM, 11TH September 2019 HYATT HOTEL, Canberra

Hello everyone, thank you for inviting me here today to speak to at the seventh Primary Health Network National Forum.

It is testament to the changing times that you now have delegates from national health peak bodies like mine, the National Aboriginal Community Controlled Health Organisation (NACCHO), attending your forums and being invited to share our own stories.

My name is Pat Turner. I am the CEO of NACCHO, and the Lead Convener of the Coalition of Peaks. Foremost, I am an Aboriginal woman, the daughter of an Arrente man and a Gurdanji woman.

Before we start, I want to acknowledge the traditional custodians of the lands where we are meeting today.

Canberra is Ngunnawal country. The Ngunnawal are the Aboriginal people of this region and its first inhabitants.

The neighbouring people are the Gundungurra to the North, the Ngarigo to the South, the Yuin on the coast, and the Wiradjuri inland.

It is a harsh climate and difficult country for hunter-gatherer people. To live here required great knowledge of the environment, skillful custodianship of it and close cooperation.

It is this knowledge and ways of working that continue to guide Aboriginal and Torres Strait Islander peoples across the in today’s Indigenous policy landscape.

As we navigate the changing policy environment, Aboriginal people draw strength from our lands and our customs. And we continue the cooperation amongst our many nations for the betterment of all of us. This is the approach that we take to the Coalition of Aboriginal and Torres Strait Islander Peaks Bodies and our work on Closing the Gap.

The Coalition of Peaks are made up of some forty national and state/territory community controlled Aboriginal and Torres Strait Islander Peak Organisations. We have come together to be formal partners with Australian Governments on Closing the Gap.

Today I want to share with you how a group of Aboriginal community controlled organisations, led by NACCHO, have exercised political agency by leading the way, challenging the possibilities and imagining a future of shared decision-making with governments on policies and programs that impact on our people and our communities.

Together, we are changing the way governments work with Aboriginal and Torres Strait Islander peoples on policies and programs that impact on us: we are setting a new benchmark for how our voices are heard in the design and implementation of policies and programs that impact on us.

I come before you to not only share the story of the Coalition of Peaks and their work with governments. Importantly, I also want to talk to you about what these new arrangements mean for Primary Health Networks and for your own daily work practices.

The new approach to Closing the Gap is a challenge you to change the way you work with and engage with Aboriginal and Torres Strait Islander people in the development of policies and delivery of health and wellbeing programs.

BACKSTORY

I will start by going back, to tell you how the Coalition of Peaks got to where we are today.

You might recall the Council of Australian Governments (COAG) in 2007 committed to ‘closing the gap’ in life expectancy between Aboriginal and Torres Strait Islander and other Australians, and a range of targets to end the disparity between Aboriginal and Torres Strait Islander peoples and other Australians in areas like infant mortality, employment and education.

  1. It was the first time that Australian Governments had come together in a unified way to address the disadvantage experienced by too many Aboriginal and Torres Strait Islander peoples.
  2. An unprecedented investment of around 4.6 billion dollars in programs and services to ‘close the gap’ as also made.
  3. Governments also agreed to new oversight, monitoring and reporting arrangements, including an annual report to the Commonwealth Parliament by the Prime Minister.

Aboriginal and Torres Strait Islander leaders at the time welcomed this new approach from governments and some of us were consulted in the early stages of the Commonwealth’s thinking.

However, despite this unprecedented coming together of Australian Governments and investment and initial engagement with our peoples, we were not formally involved in Closing the Gap, it was not agreed by us and it was a policy of governments and not for our people.

Many Aboriginal and Torres Strait Islander people felt that Closing the Gap presented the issue of our disadvantage as a technical problem built around non-Indigenous markers of poverty. This only served to hide the extent to which Aboriginal and Torres Strait Islander peoples’ disadvantage is a political problem requiring deep structural reforms about the way governments work with us.

Closing the Gap did not address the biggest gap that we face: the gulf between the political autonomy and economic resources of Aboriginal and Torres Strait Islander peoples and non-Indigenous people.

The policies and programs that then followed whilst making some difference to our peoples lives did not achieve their potential.

Over time government commitment to work together fell away. Funding to our programs and services were cut or not continued.

It is not surprising then, that, now ten years later, we have not made the progress against the closing the gap targets that had been hoped.

“REFRESH”

As you know, in 2017 the Commonwealth Government embarked on a ‘refresh’ of the Closing the Gap framework and undertook a series of consultations. In the view of many Aboriginal and Torres Strait Islander organisations, the consultations were inadequate and superficial. There was no public report prepared on their outcomes.

The lack of transparency and accountability surrounding these consultations were very disappointing, but also not surprising. Many of our organisations made submissions to government on Closing the Gap but we felt like our voices were ignored.

We were worried that governments commitment to work differently with us going forward was not backed by meaningful demonstrations. And we were concerned that governments wanted to walk away from the intergovernmental arrangements that brought a national integrated policy strategy needed to close the gap.

No new funding was announced to accompany the ‘refresh’ and there were no specific actions being discussed that we could see or feel confident would make a positive change to our lives.

As the ‘refreshed’ Closing the Gap strategy was being prepared for sign off by the Australian Governments, our dismay and disappointment galvanised a small group of community controlled organisations to come together to write to the Prime Minister, Premiers and Chief Ministers asking that it not be agreed.

We weren’t going away, and there were three important messages that we wanted governments to hear. These were:

  • When Aboriginal and Torres Strait Islander peoples are included and have a real say in the design and delivery of services that impact on them, the outcomes are far better;
  • Aboriginal and Torres Strait Islander peoples need to be at the centre of Closing the Gap policy: the gap won’t close without our full involvement; and
  • the Council of Australian Governments cannot expect us to take responsibility and work constructively with them to improve outcomes if we are excluded from the decision making.

Eventually, we were invited to meet with the Prime Minister, who acknowledged that the current targets were ‘government targets’ not ‘shared targets’, and that for Closing the Gap to be realised Aboriginal and Torres Strait Islander people had to be able to take formal responsibility for the outcomes through shared decision making.

On 12 December 2018, COAG publicly committed to developing a genuine, formal partnership with Aboriginal and Torres Strait Islander people, through their representatives, on Closing the Gap; and that through this partnership a new Closing the Gap policy would be agreed.

THE PARTNERSHIP AGREEMENT ON CLOSING THE GAP

The initial fourteen organisations then became almost forty, as we brought together Aboriginal and Torres Strait Islander Peaks bodies across the country to form a formal Coalition to negotiate a new Closing the Gap framework with Australian Governments. We include both national and state and territory based Aboriginal and Torres Strait Islander Peaks representing a diverse range of services and matter that are important to us as Aboriginal and Torres Strait Islander peoples and to Closing the Gap.

As a first step and through our initiative, we negotiated and agreed a formal Partnership Agreement between the Council of Australian Governments and the Coalition of Aboriginal and Torres Strait Islander peak organisations which came into effect in March 2019.

The Partnership Agreement sets out that the Coalition of Peaks will have shared decision making on developing, implementing and monitoring and reviewing Closing the Gap for the next ten years.

This is an historic achievement. It is the first time that Aboriginal and Torres Strait Islander Peaks have come together in this way, to work collectively and as full partners with Australian Governments. It’s is also the first time that there has been formal decision making with Aboriginal and Torres Strait Islander peoples and Australian Governments in this way.

WHERE ARE AT NOW

Progress is being made under the Partnership Agreement on Closing the Gap:

  • All Council of Australian Government members, including the local government association, have signed the Partnership Agreement.
  • The National Indigenous Reform Agreement (NIRA) has been reviewed by the Coalition of Peaks and officials from Australian Governments.
  • It has been agreed that the NIRA will be replaced with a new National Agreement on Closing the Gap covering the next ten years, to be signed off by the Council of Australian Governments and the Coalition of Peaks. It will continue the NIRA’s successful elements, strengthen others and address foundational areas that were previously excluded from consideration.
  • New accountability, monitoring and reporting arrangements are being developed for the new National Agreement that will strengthen public transparency and accountability.

Most importantly, the Coalition of Peaks have also proposed reform priorities to underpin the new National Agreement on Closing the Gap.

The reform priorities seek to change the way Australian Governments work with Aboriginal and Torres Strait Islander peoples and organisations, and accelerate life outcomes for Aboriginal and Torres Strait Islander peoples, these are:

  1. 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.
  2. Building and strengthening Aboriginal and Torres Strait Islander community-controlled organisations to deliver services and programs in priority areas.
  3. Ensuring all mainstream government agencies and institutions undertake systemic and structural transformation to contribute to Closing the Gap.

These reforms have been agreed in principle by the COAG established Joint Council on Closing the Gap, made up of Ministers from each jurisdiction and Coalition of Peak representatives on 23 August 2019. And they have direct relevance to the Primary Health Networks and our work together.

The Joint Council also agreed to the Coalition of Peaks leading engagements with Aboriginal and Torres Strait Islander representatives of communities and organisations on new National Agreement.

These engagements are happening over the next two months and include open meetings across Australia agreed to and supported by governments. The Coalition of Peaks are also consulting with their own memberships and there is an online public opportunity for people to have their say.

The primary focus of the engagements is to build understanding and support for the reform priorities and to have a detailed discussion on what is needed to make those reform priorities a success. The discussions and input from Aboriginal and Torres Strait Islander communities will help inform the finalisation of the negotiations on the New National Agreement on Closing the Gap.

This is also a significant shift in the approach to policy development. It is the first time that governments have agreed to leaders of Aboriginal and Torres Strait Islander organisations engaging with representatives from our communities and organisations about important government policy.

Pat Turner Lead Convener of the Coalition of Peaks invites community to share their voice on #ClosingtheGap

This week a survey will be sent to hundreds of Aboriginal and Torres Strait Islander community-controlled organisations and their networks, inviting responses from both individuals and organisations.

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

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

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

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

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

NACCHO welcomes call by @KenWyattMP for more Aboriginal #ACCHO input into #PHN’s Primary Health Networks

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”  Primary Health Networks are being encouraged to consider the skills of the National Aboriginal Controlled Community Health Organisation ( NACCHO ) and Aboriginal Community Controlled Health (ACCHO’s ) groups to assist delivering innovative health programs to Close the Gap in health outcomes.

Broadening the range of member organisations involved in the Primary Health Networks, and ensuring an appropriate range of skills on their boards, would help ensure the specific needs of the diverse groups in our community are considered when commissioning health services.”

The Minister for Indigenous Health, Ken Wyatt AM, MP

Press Release 1 March 2017

 ” I applaud the National Aboriginal Community Controlled Health Organisation for commissioning this annual report for the benefit of the entire sector. This Healthy Futures report is an invaluable resource because it provides a comprehensive picture of a point in time.

These report cards allow the sector to track progress, celebrate success, and see where improvements need to be made.

This is critical for the continuous improvement of the Aboriginal Community Controlled Health Sector as well as a way to maintain focus  and achieve goals.

We need to acknowledge the great system in place that comprises the network of Aboriginal Community Controlled Health Organisations, and recognise the role you play to build culturally responsive services in the mainstream system.

Our people need to feel culturally safe in the mainstream health system; the Aboriginal Community Controlled Health sector must continue to play a central role in helping the mainstream services and the sector to be culturally safe “

Photo above : The Hon Ken Wyatt AM,MP :Text from  SPEECH NACCHO MEMBERS CONFERENCE 2016 Launch of the Healthy Futures Report Card 8 December 2016 Melbourne

PHN’S  should ensure all Aboriginal Community Controlled Health Organisation’s, their regional bodies and state peaks are the preferred providers for any targeted Aboriginal and Torres Strait Islander programs.

They should also have representation from Aboriginal Community Controlled Health Organisation’s on their Board of Directors, Clinical Councils and Community Advisory Committees.

And they should put into practice the guiding principles developed by NACCHO and PHN’s with the Department of Health Indigenous Health Division.

These simple but critical steps will ensure Primary Health Networks facilitate the best available service, in the most culturally appropriate way, to the Aboriginal and Torres Strait Islander people in their region and ultimately have the best chance of improving their health outcomes.”

Matthew Cooke NACCHO Chair Press Release March 2 see below

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Pictured above Minister Wyatt signing the Close the Gap Statement of Intent 2008

Ken Wyatt Press Release

“Primary Health Networks across the country are charged with increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes, and improving coordination of care and services to ensure patients receive the right care, in the right place, at the right time,” he said.

“Improving the health of Aboriginal and Torres Strait Islander people is a key priority for all Primary Health Networks.

“They should consider whether their current member organisations and boards have the appropriate mix of skills, knowledge, experience and capabilities to deliver the best health outcomes and if this could be improved.

“Primary Health Networks have a vital role to play in improving the health of Aboriginal and Torres Strait Islander people.

“Having a broad skills base is crucial to achieving this goal and I look forward to working with all Primary Health Networks to support the continued delivery of high quality primary health care services to all Australians.”

naccho-1703-mr-phns

The peak Aboriginal health organisation today welcomed calls by the Minister for Indigenous Health, Ken Wyatt, to better integrate the skills and experience of Aboriginal community controlled health organisations into Primary Health Networks.

National Aboriginal Community Controlled Health Organisation (NACCHO) Chair, Matthew Cooke, said this was something Aboriginal people had been calling for since the introduction of Primary Health Networks (PHNs) and it was great to see the Minister take it on board.

“The evidence tells us that Aboriginal people respond best to health care provided by Aboriginal people or controlled by the Aboriginal community,” Mr Cooke said.

“Armed with this evidence, Primary Health Networks should be doing everything they can to make sure Aboriginal people are involved in their structures and programs.

“They need to better recognise and acknowledge the experience, history and expertise within the Aboriginal Community Controlled Health sector.

Aboriginal Community Controlled Health Organisation provided almost 3 million episodes of care to over 340,000 clients over the last 12 months and employ 3,300 Indigenous staff across Australia which makes them the largest single employer of Aboriginal and Torres Strait Islander people in the nation.

Read or Download more facts from

 NACCHO 2016 Healthy Futures report card here

naccho-healthy-futures-report-card-2016

“They should ensure all Aboriginal Community Controlled Health Organisation’s, their regional bodies and state peaks are the preferred providers for any targeted Aboriginal and Torres Strait Islander programs.

“Ken Wyatt is to be commended for his leadership in encouraging PHNs to take a look at their structures and question whether they have the relevant expertise at hand.

“Our services across the country welcome the opportunity to work with the Minister and the PHNs to offer the best of support and primary care to Aboriginal and Torres Strait Islander people.”

          140-members

NACCHO Aboriginal Community Controlled Health

Our recent Member’s Good News Stories from WA, NSW ,VIC ,SA, QLD, NT

NACCHO Health News : How could Public Health Networks ( PHN’s ) improve health care coordination in partnership with Aboriginal communities ?

 

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“This article outlines how PHNs might support health services to systematically and strategically improve their responsiveness to Aboriginal and Torres Strait Islander peoples within their boundaries according to ten proposals.

These best practice models and examples can assist PHNs to adapt their strategic plans to optimally respond to this priority.”

Picture above : “Aboriginal health in Aboriginal hands ” : Susan Leslie-Briggs and Lisa Tighe in Moree NSW

Photo Wayne Quilliam from NACCHO TV series / photo exhibition touring Australia from May 2016

One of six priorities set by the Australian Government is for Primary Health Networks (PHNs) to focus on the health of Aboriginal and Torres Strait Islander peoples.1 Announced in the 2014–15 federal Budget, PHNs aim to coordinate primary health care provision especially for those at risk of poor health outcomes.

There are 31 PHNs across Australia with several formed from consortia of Local Hospital Networks (LHNs). Operational and flexible funding of up to $842 million was committed for PHNs over 3 years from 2015–16.2

It is timely for PHNs to consider how they will improve health care coordination in partnership with Aboriginal and Torres Strait Islander communities in their respective regions.

Efforts to reduce the high hospitalisation rates of Aboriginal and Torres Strait Islander people will require PHNs to build formal participatory structures to support best practice service models. Comprehensive primary health care can then be shaped by the needs of the community rather than by ad hoc factors or reactions to financial incentives and health care funding arrangements.3,4 Collaborations with Aboriginal community controlled health services (ACCHSs) within PHN regions have been recommended.5,6

This article outlines how PHNs might support health services to systematically and strategically improve their responsiveness to Aboriginal and Torres Strait Islander peoples within their boundaries according to ten proposals. These best practice models and examples can assist PHNs to adapt their strategic plans to optimally respond to this priority.

Summary

  • The Australian Government has established that the health of Aboriginal and Torres Strait Islander peoples is a priority for the newly established 31 Primary Health Networks (PHNs). Efforts to reduce the high hospitalisation rates of Aboriginal people will require PHNs to build formal participatory structures with Aboriginal health organisations to support best practice service models.
  • There are precedents as to how PHNs can build formal partnerships with Aboriginal community controlled health services (ACCHSs), establish an Aboriginal and Torres Strait Islander steering committee to guide strategic plan development, and work towards optimising comprehensive primary care.
  • All health services within PHN boundaries can be supported to systematically and strategically improve their responsiveness to Aboriginal and Torres Strait Islander people by assessing systems of care, adopting best practice models, embedding quality assurance activity, and participating in performance reporting.
  • PHNs can be guided to adopt an Aboriginal and Torres Strait Islander-specific quality improvement framework, agree to local performance measures, review specialist and other outreach services to better integrate with primary health care, enhance the cultural competence of services, and measure and respond to progress in reducing potentially preventable hospitalisations.
  • Through collaborations and capacity building, PHNs can transition certain health services towards greater Aboriginal community control.
  • These proposals may assist policy makers to develop organisational performance reporting on PHN efforts to close the gap in Aboriginal health disparity.
  1. Collaborate with ACCHSs

ACCHSs are authorities on comprehensive primary health care matters at the local level4,7 and do much more than just cure illness.8 As authentic representational advocates, they can guide PHN responsiveness to Aboriginal and Torres Strait Islander health issues and, with more than 150 services across Australia, there are ACCHSs within the regional boundaries of every PHN.

The predecessors of PHNs — the Medicare Locals — were expected to engage with ACCHSs for many Closing the Gap initiatives, such as the Indigenous Chronic Disease Package (ICDP), from 2008.9 Where meaningful partnerships between ACCHSs and Medicare Locals were established in the delivery of these programs, health outcomes for Aboriginal people substantially improved (Box 1).10

  1. Establish an Aboriginal and Torres Strait Islander steering committee

PHNs can foster meaningful Aboriginal community engagement by establishing an Aboriginal and Torres Strait Islander steering committee (and Aboriginal) representation on the PHN board) with membership led by ACCHSs representatives inclusive of other Aboriginal health service organisations. Similar partnership forums established between the ACCHS, general practice sectors, and state and territory governments have set Aboriginal health priorities at the jurisdictional and regional level for decades.11 The steering committee aims might be modelled on current partnerships between the LHN and ACCHSs (Appendix 1) to develop a strategic plan across the life course.

  1. Establish formal agreements to support the strategic plan

PHNs should aim for partnerships to reorient health services from reactionary care to comprehensive primary health care. For example, in remote Western Australia, a partnership agreement between an ACCHS and state government health services was associated with a reversal of the increasing trend in hospital emergency department attendances among other substantial health improvements in only 6 years12 (Box 2).

Partnership agreements between PHNs, ACCHSs and other agencies should support Aboriginal leadership, quality care, accountability and patient-centredness, and should be formalised from non-binding memoranda of understanding to binding contracts (Box 1 and Box 2) to support a long-term vision for core activity that is flexible to local priorities.

  1. Support health services to assess their systems of care

There are now health system assessment tools specifically adapted to optimise the primary health care of Indigenous Australians based on the Chronic Care Model.13 Over 200 Aboriginal primary health care services have used such tools (Appendix 2). Many ACCHSs self-audit their performance using clinical audit tools for chronic disease, maternal and child health and other health priorities, and undertake generic health systems assessment as part of continuous quality improvement (CQI).14

Health system assessment and audits of actual practice against best practice standards should be used to guide PHN (and LHN where there is conjoint responsibility) priorities to systematically enhance quality care within all primary care services in PHN boundaries. Barriers to and enablers for systems improvement, and gaps in health service responsiveness to Aboriginal health needs, will be clearer. These include improving systems for follow-up of patients, use of electronic registers and recalls, Aboriginal community engagement and leadership, the commitment of workforce and management, service infrastructure, and staff training and support.14,15

  1. Embed quality assurance activity within primary health care services

A commitment to CQI is a key strategy for disease prevention (Appendix 3) and the prevention of avoidable hospitalisations (Appendix 4), and should be a universal feature of primary health care services providing care to Aboriginal and Torres Strait Islander peoples.15

A national Aboriginal and Torres Strait Islander CQI framework supported by the Australian Government will shortly be released to guide jurisdictions to assess and deliver better quality primary health care.16 PHNs should endorse and adapt this framework to coordinate efforts and develop CQI implementation plans. For example, most state and territory affiliates of the National Aboriginal Community Controlled Health Organisation provide support to ACCHSs for CQI activities; and in some jurisdictions (Queensland and the Northern Territory), CQI support programs are well developed.14

PHNs will need to engage with existing programs to identify strategies for and barriers to CQI. Supporting CQI within the network boundary will require regional facilitators, trained staff, the coordinated use of shared electronic medical records and use of local information management systems by all providers (including locums and visiting services), regular monitoring of CQI indicators, performance reporting, and agreements on data use, ownership and reporting.14

  1. Expand primary health care performance reporting

All primary health care services within each PHN delivering care to Aboriginal people (and especially in receipt of financial grants or incentives specific to Indigenous Australians) should be required to undertake CQI, and to participate in regional or centralised performance reporting which can be disaggregated by Aboriginality. Primary health care performance should be a core responsibility of quality, safety and risk subcommittees of both PHNs and LHNs.3 Aggregated CQI data at PHN levels can identify health service gaps and areas that need to be improved.16

The Australian Government reporting framework for PHNs will include national, local and organisational performance indicators.17 National indicators for PHNs will include primary and community health indicators such as potentially preventable hospitalisations (these will be sourced from existing datasets such as the National Hospital Morbidity Database) not unlike what is currently reported for LHNs. Potentially preventable hospitalisations are an indirect measure of whether people are receiving adequate primary health care. The disproportionately high rate of illness affecting Aboriginal people and their poorer access to primary health care explains higher potentially preventable hospitalisation rates independent of age, sex and remoteness (Appendix 4). Age-standardised potentially preventable hospitalisation rates within PHN boundaries should be disaggregated by Aboriginality and incorporated as a performance indicator within PHN strategic plans.

The selection of local and organisational performance indicators by PHNs should be guided by the Aboriginal steering committee. Benchmarking PHN progress using Aboriginal and Torres Strait Islander national key performance indicators18 should be considered. National key performance indicators serve as both a CQI tool and performance measure in the provision of primary health care to Indigenous Australians. For example, ACCHSs are required to report on 19 key performance indicators through a standardised portal supported by the Australian Government.7 Organisational performance reporting of PHN activity should quantify the allocation of funds towards Aboriginal programs and contractors and whether they are ACCHSs or other services.

  1. Align and endorse PHN and LHN strategic plans

Commitment to region-specific Aboriginal primary health care strategic plans should be the goal for both PHN and LHN boards so that actions are informed by both and integrated to avoid cross purposes.3 These linkages might be streamlined in regions where PHNs have been established by LHNs. However, it is unclear how many LHNs have established Aboriginal health subcommittees or effective and formalised Aboriginal community engagement mechanisms to facilitate endorsement of strategic plans.

All PHNs are expected to complete baseline needs assessment and strategies to respond to service gaps.19 If these submissions pertain to the Aboriginal and Torres Strait Islander population, they should be accompanied by evidence of endorsement by the Aboriginal representative bodies in their region.

  1. Strengthen the primary health care service model

Many visiting health providers can overburden Aboriginal people in remote communities with overlapping and poorly explained services.20 A core priority for PHNs is to review the coordination of care and improve clinical pathways in all geographic regions. PHNs will need to review the efficiency of current services including generalist and specialist outreach if they are to avoid duplication, foster local or residential health services,21 and sustain local CQI systems.

Specialist outreach should complement local health services through a bottom-up approach integrated with primary health care. Specialist outreach services operating independently of existing primary health care services will need review. Service reforms might mean building hub-and-spoke models involving ACCHSs, supporting regional Aboriginal health networks (Box 1), using telehealth adapted for Aboriginal and Torres Strait Islander settings, renegotiating clinical pathways, empowering local outreach coordinators of hospitals to support primary health care models, substituting workforce tasks through nurse and Aboriginal and Torres Strait Islander health practitioners, rural generalists and physician assistants,22 and reorienting health services towards primary health care (Box 2, Appendix 5).

  1. Enhance cultural competence of PHC services

Strategies to merely increase the awareness of non-Indigenous health staff to Aboriginal cultural protocols are often recommended to reduce Aboriginal health disparities, but may not lead to cultural competence.23 Some staff still struggle with how to make services culturally responsive beyond the posting of Aboriginal artwork.20 The ICDP invested in cultural awareness training of over 6000 general practice staff but change in practice was not universally embraced.8,15

Enhancing the cultural competence of health services within PHN boundaries will require strategies best managed by the Aboriginal steering committee and may include subcontracting ACCHSs and expanding their outreach role, person-centred and family-oriented care, fostering a culturally identified workforce that reflects the patient population and health needs, staff training in cultural safety, performance measures for cultural competence, and future planning.

  1. Transition primary health care services to Aboriginal community control

PHNs are to be the health “providers of last resort and their decision to directly provide services should require the approval of the Department of Health”.3 Agreement from local ACCHSs in the region should be required if a PHN opts to directly provide health services to Aboriginal communities rather than make purchasing arrangements with existing Aboriginal services (Box 1). ACCHSs should also be supported to choose their involvement in programs within the PHN boundary.

Coalitions of Aboriginal organisations have advised that future funding on Indigenous health programs be prioritised to ACCHSs being better placed to meet Aboriginal health needs with better returns on investment.24 For example, according to the ICDP evaluation, it was unclear whether Closing the Gap measures (such as financial incentives to general practices) increased the provision of services to Aboriginal people who are “hard to reach” or increased their access to primary health care.9,15 For PHNs, it makes sense to direct Aboriginal health strategies to health services with the desire and potential to provide quality care to Aboriginal patients, which is also more cost-effective.15

The Queensland and Northern Territory governments have commenced processes to transition certain health services in remote areas to Aboriginal community control.25,26 The aim is to reform remote area services from doctor-focused, illness-centred, acute hospital-based primary care services to community-engaged, comprehensive, preventive and responsive systems. Policy frameworks propose staged approaches and capacity building of existing ACCHSs. Strategic plans developed by PHNs should consider transitioning health services and responding to existing transition plans26 to ensure alignment with them.

Conclusion

These proposals offer policy makers and PHNs a framework for health service planning within newly established boundaries, and may inform PHN organisational performance reporting on efforts to close the gap in Aboriginal health disparity.

Australians report that our health system is not sufficiently patient focused. Primary care is reactive and episodic, funding structures support providers and not patients, and there is little accountability for health outcomes.4 Through existing and better targeted additional investments, PHNs can offer Aboriginal and Torres Strait Islander people some hope towards reforming access to and quality of primary health care in their localities, but only if programs and systems can better fit in with community needs. To close the gap, PHNs need to support Aboriginal communities towards greater participation in primary health care, ultimately through the expression of community control.

Acknowledgements: We acknowledge the assistance of Shaun Solomon, Head of Indigenous Health at the Mount Isa Centre for Rural and Remote Health, James Cook University, for reviewing an early draft.

Competing interests: No relevant disclosures.

Provenance: Not commissioned; externally peer reviewed.

Author details

Sophia Couzos FAFPHM, FACRRM, FRACGP1 3

Dea Delaney-Thiele PGDipHlthMgt, MPH, Doctoral Candidate UNSW. 2

Priscilla Page BASc1 3

1 College of Medicine and Dentistry, James Cook University, Townsville, QLD.

2 Nepean Aboriginal Health Service , Penrith, NSW , Sydney, NSW.

  1. Anton Breinl Research Centre for Health Systems Strengthening, Townsville, Qld.

sophia.couzos@jcu.edu.au

doi: 10.5694/mja15.00975

References

References

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  2. Department of Health. Primary Health Networks: grant programme guidelines. Canberra: Australian Government, 2014. https://www.health.gov.au/internet/main/publishing.nsf/Content/00069147C384180DCA257F14008364CB/$File/guidelines.pdf (accessed Feb 2016)
  3. Horvath J. Review of Medicare Locals. Report to the Minister for Health and Minister for Sport. Australian Government, Canberra, 2014. http://www.health.gov.au/internet/main/publishing.nsf/content/review-medicare-locals-final-report (accessed Aug 2015)
  4. Australian Government. Reform of the Federation. Discussion Paper. Australian Government, 2015 https: //federation.dpmc.gov.au/sites/default/files/publications/reform_of_the_federation_discussion_paper.pdf (accessed Nov 2015)
  5. Australian Healthcare and Hospitals Association. Primary Health Network discussion paper series: Paper three. Aboriginal and Torres Strait Islander health. AHHA, Canberra, 2015. https: //ahha.asn.au/primary_health (accessed Nov 2015)
  6. United General Practice Australia. Principles for Primary Health Networks. UGPA, 2015. https: //gpra.org.au/ugpa/ (accessed Aug 2015)
  7. Panaretto KS, Wenitong M, Button S, Ring IT. Aboriginal community controlled health services: leading the way in primary care. Med J Aust 2014; 200: 649-52
  8. Baba JT, Brolan CE, Hill PS. Aboriginal medical services cure more than illness: a qualitative study of how Indigenous services address the health impacts of discrimination in Brisbane communities. Int J Equity Health 2014; 13: 56: 1-10.
  9. KPMG Australia. National Monitoring and Evaluation of the Indigenous Chronic Disease Package: Summary Report. Australian Government Department of Health, Canberra, 2014. http://www.health.gov.au/internet/main/publishing.nsf/Content/icdp-national-monitoring-evaluation (accessed Nov 2015)
  10. Institute for Urban Indigenous Health. 2013-14 Annual Report. IUIH, Brisbane, 2014: 16. http://www.iuih.org.au/Portals/0/PDF/AnnualReport_2014.pdf (accessed Nov 2015)
  11. Close the gap steering committee for Indigenous health equality. Partnership position paper. Oxfam Australia, 2010 https: //www.humanrights.gov.au/sites/default/files/content/pdf/social_justice/health/partnership_position_paper.pdf (accessed Nov 2015)
  12. Reeve C, Humphreys J, Wakerman J et al. Strengthening primary health care: achieving health gains in a remote region of Australia. Med J Aust 2015; 202: 483-7.
  13. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002; 288: 1775-9.
  14. Wise M, Angus S, Harris E, Parker S. National Appraisal of Continuous Quality Improvement Initiatives in Aboriginal and Torres Strait Islander Primary Health Care. The Lowitja Institute, Melbourne, 2013. https: //www.lowitja.org.au/sites/default/files/docs/National-Appraisal-of-CQI-FINAL.pdf (accessed Nov 2015)
  15. Bailie R, Griffin J, Kelaher M et al. Sentinel Sites Evaluation: Final Report. Report prepared by Menzies School of Health Research for the Australian Government Department of Health, Canberra. 2013 http://www.menzies.edu.au/icms_docs/189996_Sentinel_Sites_Evaluation_Final_Report.pdf (accessed Nov 2015)
  16. Lowitja Institute. Recommendations for a National CQI Framework for Aboriginal and Torres Strait Islander Primary Health Care. Australian Government, Department of Health. Canberra, 2014. http://www.health.gov.au/internet/main/publishing.nsf/content/cqi-framework-atsih (accessed Aug 2015)
  17. Department of Health. Primary Health network performance framework. Australian Government, Canberra, 2015. http://www.health.gov.au/internet/main/publishing.nsf/Content/phn-performance (accessed Nov 2015)
  18. Australian Institute of Health and Welfare. Healthy Futures- Aboriginal Community Controlled Health Services: Report Card (Cat. no. IHW 150). AIHW, Canberra, 2015 http://www.aihw.gov.au/publication-detail/?id=60129550479 (accessed Nov 2015)
  19. Australian Government. Health Portfolio Budget Statements 2015-16. Outcome 5- Primary Health Care. Department of Health, Canberra, 2015. http://www.health.gov.au/internet/budget/publishing.nsf/Content/2015-2016_Health_PBS (accessed Nov 2015)
  20. McBain-Rigg KE, Veitch C. Cultural barriers to healthcare for Aboriginal and Torres Strait Islanders in Mt Isa. Aust J Rural Health 2011; 19: 70-74.
  21. House of Representatives Standing Committee on Regional Australia. Cancer of the bush or salvation for our cities? Fly-in, fly-out and drive-in, drive-out workforce practices in regional Australia. Parliament of Australia,Canberra, 2013. http://www.aph.gov.au/parliamentary_business/committees/house_of_representatives_committees?url=ra/fifodido/report.htm (accessed Aug 2015).
  22. Productivity Commission. Efficiency in Health, Commission Research Paper, Canberra, 2015. http://www.pc.gov.au/research/completed/efficiency-health (accessed Nov 2015)
  23. Durey A. Reducing racism in Aboriginal health care in Australia: where does cultural education fit? ANZJPH 2010; 34: S87-92
  24. Close the Gap Campaign Steering Committee for Indigenous Health Equality. Progress and Priorities Report 2015. Australian Human Rights Commission, 2015. https: //www.humanrights.gov.au/sites/default/files/document/publication/CTG_progress_and_priorities_report_2015.pdf (accessed Nov 2015)
  25. Department of Health and Ageing. Section 5.5- Regionalisation and Aboriginal community control. In: Evaluation of the Child Health Check Initiative and the Expanding Health Service Delivery Initiative: Final report. Australian Government. Canberra, 2011. https: //www.healthstarrating.gov.au/internet/publications/publishing.nsf/Content/oatsih-chci-ehsdi-toc~oatsih-chci-ehsdi-5~oatsih-chci-ehsdi-5-5 (accessed Nov 2015)
  26. Queensland Health. Transition to Aboriginal and Torres Strait Islander community control of health in Queensland: A draft strategic policy framework. Queensland Government. [Undated] https: //www.health.qld.gov.au/atsihealth/transition_cc.asp (accessed Aug 2015)

[Boxes]

1 Example: collaboration between Medicare Locals and Aboriginal community controlled health services

In 2008, to close the gap in Aboriginal health disparity, the Indigenous Chronic Disease Program funded the Care Coordination and Supplementary Services (CCSS) program. The program supports Aboriginal and Torres Strait Islander patients with complex care needs, by coordinating clinical care and providing supplementary funding for allied health, specialists, transport services and medical aids. Implementation required collaborations between Aboriginal and mainstream health services. In South-East Queensland, the Metro North Brisbane Medicare Local (MNBML) was funded to deliver the CCSS program on behalf of four other Medicare Locals in South-East Queensland. A consortium of ACCHSs — the Institute for Urban Indigenous Health (IUIH) — was subcontracted by the MNBML to implement the program in 2013–14. IUIH employed a manager to oversee the program delivered by 20.5 full-time equivalent care coordinators.

The IUIH reported that subcontracting delivered significantly more services to significantly more Indigenous Australians with complex chronic conditions than any other part of the country: “In 2013–14 IUIH and members [ACCHSs] delivered over 57 000 episodes of care via the CCSS Program. The delivery of intensive case management and access to a comprehensive range of specialist and allied health services and medical aides for this population has avoided costly hospital admissions for Government and significantly improved the health and wellbeing of some of our most vulnerable and unwell patients.”10

2 Example: a partnership to reorient acute care to comprehensive primary health care

Clinic services in the very remote Fitzroy Valley in Western Australia are delivered by state government health services (Fitzroy Crossing Hospital and the Kimberley Population Health Unit for community health services). Non-clinical health services are delivered by the Aboriginal community controlled health service (Nindilingarri Cultural Health Services) to a population of 3500 (80% Aboriginal). These services comprise healthy lifestyle programs designed around Aboriginal culture. A formal agreement between the agencies was negotiated in 2006 to form a single governance structure to allocate funding, share an e-health record, and coordinate health promotion, cultural safety, acute inpatient care, primary care and specialist care, and population-based screening. Commonwealth funding supported the development of a shared e-health record for quality improvement and additional staff (through the Healthy for Life and Indigenous Chronic Disease programs), and provided Medicare rebates to patients for primary care services delivered at the hospital clinic (an exemption from section 19(2) of the National Health Insurance Act 1973). Medicare billings were reinvested to support this reorientation under the guidance of the partners.

This reorientation enhanced health promotion programs and was associated with a reversal of the increasing trend in emergency department attendances. In the primary care clinic, there was a substantial increase in the number of patients seen, the number of health checks, the detection of risk factors, the proportion of patients with diabetes having care plans, transport provision, cultural security and follow-up attendances in only 6 years.12

KME623p037 naccho V2

Out 6 April as a FREE  24 Page lift out in the Koori Mail

Election 2016, it’s time to encourage all political parties to focus on Aboriginal health

With an early Federal Election looking likely, it’s time to encourage all political parties to focus on Aboriginal health and the critical role of the community controlled sector in improving services and health outcomes for Aboriginal and Torres Strait Islander people.

The Turnbull Government has flagged it will call a Double Dissolution Election on July 2 if the Senate refuses to pass the Australian Building and Construction Commission (ABCC) Bill, targeting unions. The Prime Minister has until May 11 to call the poll.

A decade after governments agreed to bipartisan support for the Close the Gap agreement, the National Aboriginal Community Controlled Health Organisation (NACCHO) Chairperson, Matthew Cooke, said long term commitment from politicians to strengthen and grow the community controlled sector, through partnership with it, must be a priority for all political parties.

“One of the principles that is espoused by all levels of government on Aboriginal issues is that engagement with Aboriginal communities and organisations is the only way to successfully close the gap,” Mr. Cooke said.

“Time and again we see evidence that supports that principle.

“Our own sector, managed by Aboriginal people for Aboriginal people, is making the biggest in-roads against the Closing the Gap health targets.

“Our services provide over two million episodes of care nationally each year and have made the biggest gains against the targets to halve child mortality and improve maternal health. “

“Indeed, our services have successfully contributed to the Close the Gap targets that have reduced child mortality rates by 66% and overall mortality rates of Aboriginal and Torres Strait Islander people by 33% over the last two decades.

Read more in NACCHO Aboriginal Health Newspaper