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MEDICARE reform that supports GP advocacy for Aboriginal and Torres Strait Islander patients is crucial to finally closing the gap and eliminating systemic racism in Australia’s health care system, say experts.
In an editorial published by the MJA, Professor Lilon Bandler, a GP and Principal Research Fellow at the Leaders in Indigenous Medical Education Network, and Dr Talila Milroy, a GP and academic registrar with the University of Western Australia, wrote that “general practice must be the cornerstone for restructuring Indigenous health policy, and this must include reforming Medicare”.
“As GPs, we see how health care in Australia fails to adequately serve Aboriginal and Torres Strait Islander Australians,” Milroy and Bandler wrote.
In 2020, the federal government changed its approach to the Closing the Gap policy, pivoting to “the incorporation of Indigenous perspectives into health care, and greater control of health-related targets and programs by Indigenous-led organisations”.
“We see the risks associated with the new Closing the Gap policies in community primary health care,” wrote Milroy and Bandler.
“The social determinants of health have long been clear, but the model of care expected of Australian GPs does not acknowledge that housing, food security, and protection from the effects of climate change are as important as a referral to a podiatrist when managing someone with diabetes.”
Speaking in an exclusive InSight+ podcast, Professor Bandler said that Medicare reform was vital to supporting Indigenous health.
“One of the things that draws my attention to Medicare is that it doesn’t reward sitting and listening and taking time,” Professor Bandler said.
“That, particularly for Aboriginal and Torres Strait Islander patients and their families, is a real problem. They will report this sense of being hurried through and being part of the churn of the day-to-day business of a practice.
“And the reality is that for private practices, [with Medicare as it is,] it is important to see a lot of patients to make it financially viable.
“It also goes to some issues around the complexity of many Aboriginal and Torres Strait Islander patients’ health care. So, any patient who has a complex medical history will probably identify with that, but those people are over-represented in Aboriginal and Torres Strait Islander patients.”
Both Milroy and Bandler acknowledged that they were asking big questions of the Australian Government and society in general.
“We are talking systemic racism,” said Professor Bandler.
“We are asking huge things of Australia more broadly. And that is reflected in what we ask of an Australian federal government. The challenge of that is for Australian society and for the Australian federal government as the representatives of that society. And that is why asking for change is something you grow gray hairs doing.”
Professor Bandler told InSight+ that there were “steps along the way”.
“The health care professionals in Australia are thinking about culturally safe care and how they reflect on their own practice and what that means in terms of how they might change their practice, and how they might reflect on their values and their impact on Aboriginal and Torres Strait Islander patients.
“We also recognise that it’s not just about policy.
“It is about people and how people live and interact with their health care professionals. That it is complex and difficult.”
Medical education, not just of Indigenous students and junior doctors, but also of their supervisors and mentors, remains an area full of challenges.
Dr Milroy told InSight+ that even though “Indigenous doctors relate really well with Indigenous patients … it’s been hard to grow this sector”.
“We have streamlined pathways for Indigenous people to move into medical and health-related fields through universities, but there are barriers to people progressing after they graduate into specialty training,” she said.
“Racism is thought to be a big contributor to that. It’s talking about supervisors who may not be aware of the issues that their Indigenous trainees might be experiencing with their training.
“This might include things like racism directed from patients in day-to-day practice and how they deal with that; also access to culturally appropriate mentorship. Colleges are trying to improve that, but if there’s not a lot of people to provide that mentorship at the top, then then you have difficulties when you’ve got a lot of trainees who need that support.
“So again, it’s about system change.
“We need to address the issues of racism across health care, education, training, and health care delivery to support trainees and to support these culturally safe workplaces.”
In concluding their MJA editorial, Milroy and Bandler wrote that:
“The benefits in closing these gaps go beyond fulfilling a policy agenda, providing new health services, or establishing new programs. It means future generations of Indigenous Australians who live longer, who thrive rather than survive, and who are recognised as valued members of the society and country they own.”
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The poor health status of Aboriginal and Torres Strait Islander peoples is a result of a complex range of factors, including the ongoing effects of colonisation,social inter-generational trauma, racism and the relationship between the social / cultural determinants and health and wellbeing. Of course, undoubtedly many Aboriginal and Torres Strait Islander pwersons across the nation enjoy access to excellent health care from private general practices, community health centres and ACCHSs. Indeed, access to high-quality primary health care forms the foundation of the National Aboriginal and Torres Strait Islander Health Plan 2013–2023 to improve health outcomes for Aboriginal and Torres Strait Islander people and communities. However, as reported by the AIHW in its Aboriginal and Torres Strait Islander Health Performance Framewrok 2020 Report some 29 medium-sized areas across both inner and outer Regional areas and across Remote and Very remote areas have Indigenous populations with no Indigenous-specific primary health care services within one hour’s drive and relatively poor access to GP services in general.
The tyranny of disance across this vast Continent of ours acts as a a barrier to access as do other factors such as disliking a service, ‘being too afraid’, culturally inappropriate services, poor communication from health professionals, services having insufficient time and other responsibilities, and experiences of racism – all of which compromise the quality of medical care, as is so aptly pointed out by the RACGP in its Position Statement titled ‘A stringer primary health system for Aboriginal and Torres Strait Islander peoples through health reform’ issued in July 2020, As an aside, increasing the representation of Aboriginal and Torres Strait Islander people in the health workforce is one way to overcome racism and to improve access to culturally appropriate health services for Indigenous Australians.
As the RACGP Position Staement referred to abive advises, on the the issue of cost, in the primary health care and GP context, the MBS rebate values do not adequately compensate practitioners for the complexity, skill and time of health care delivery across all population groups, including Aboriginal and Torres Strait Islander peoples. Further as the Position Staement advises, the Practice Incentives Program – Indigenous Health Incentive (PIP-IHI) initiative, as a targeted funding source, supports improvements to Aboriginal and Torres Strait Islander health and represents an alternative funding stream to the MBS.. Those familair with the PIP-IHI initiative willl know that its helps general practices and Indigenous health services provide better health care for Aboriginal and/or Torres Strait Islander patients, including best practice management of chronic disease. As the RACGP Position Statement furthr advises, the PIP-IH(I is often coupled with the Cl;osing the Gap PBS Co-payment Measure, which provides free or low-cost PBS medicines to eligible Indigenous patients who are living with, or at risk of, chronic disease and thus improves ccess to same.
.The PIP-IHI program is particularly important to enable ACCHOs and other practices that service a large population of Indigenous persons in delivering a comprehensive array quality primary health care services. The issue is wheher or not the PIP-IHI program is feasible in those communities with smaller numbers of Indigenous persons. Nverthe;less, as the RACGP Position Statemnent advises, continued investment in the PIP– IHI is warranted, with some consideration to optimise the delivery of high-quality chronic disease care, and to recognise the complexity and skill required to deliver Aboriginal and Torres Strait Islander primary health care.
The College’s Position Statement proffers that the benefits of general practice are optimised when included as part of a broader comprehensive, coordinated multidisciplinary primary care team. This might auger well for Indigenous peoples living in Major cities and larger Regional area towns where the availability of and access to allied health services would be much easier. However, the same could not always be said for those Indigenous Australians who live in Remote and Very remote areas. Indeed, getting say, a psychologist or podiatrist to work in ‘outback’ Australia is sometimes a challenge.
Systemic racism in Healthcare. Apart from the strong assertion that it exists, there was no evidence to support this assertion. We are ethically bound to treat all our patients the same way and that applies to non-english speakers and others from culturally and linguistically diverse backgrounds. But medicine is a science as well as an art. We must offer advice and provide treatment based on the best available scientific evidence. Culturally safe medicine may not be medically safe medicine – perhaps we can have a definition that identifies the difference. 10 min medicine is a scourge , but it is one that is equally applied to all. The solution is not Medicare, it is a group of salaried doctors who are not governed by the tyranny of turnover and are able to spend the time that complex indigenous and other patients require.
I am getting tired of the term Aboriginal and Torres Strait islander being used everywhere as If this is a homogeneous group.
It is anything but.
The photograph of obviously remote community children as if this represents all ASTI’s is political not medical clinical.
This is so unscientific.
The majority of people with ASTI heritage are urban dwelling and have the same opportunity and access as every other urban
dweller to modern treatment
As Stan Grant has highlighted there is now a huge middle class, educated, integrated, political cohort of ASTI’ Australian citizens
who are piggy backing on the media promoting the GAP and homogeneity of ATSI’ citizens.
This even infects the research literature.
If we are going to go along with this divisiveness then be truthful about the fact that ATSI citizens now have divided into the some
demographic gradients as all other Australian citizens.
Geographically, genetically, economically, socially the ASTI cohort are heterogeneous not homogeneous anymore, if they ever were.
250 seperate languages.
Public health practitioners have known for many decades that education is central to improving the social determinants of health for Aboriginal and Torres Strait Islander People, potentially offering a much wider array of choices for them to overcome the many obstacles which far too often perpetuate a vicious cycle of poverty and poor health.
Instead of useless squabbling over semantics and focus, where debating points may be found by the narrow minded on both sides, all thoughtful Australians must facilitate the pathways by which Aboriginal and Torres Strait Islander people are able to reap the benefits to be obtained from high quality education, including health education.
“…the model of care expected of Australian GPs does not acknowledge that … protection from the effects of climate change are as important as a referral to a podiatrist when managing someone with diabetes.”
Such an unfocussed and scattergun approach – slaying all the usual dragons along the way (climate change my goodness) – is the reason why no progress has been made.
Perhaps, rather than being “systemic racism”, there are actually difficulties in attempting resource allocation and service delivery for far-flung remote communities; maybe it isn’t possible to make those postings attractive enough for personnel to work there. And being accused of racism does not actually incline one to help out.
And by making Closing The Gap overtly political, people of goodwill who might have been inclined to contribute are driven away.
That’s not systemic racism either, but rather alienation forced by overly ambitious activists trying to bundle up too many of their pet projects to ride on the coat-tails of necessary improvements in Aboriginal healthcare provision.