Unrecognised potential of Indigenous health workers and practitioners

BEING a Kuku Yalanji man from the Mossman–Daintree area of Far North Queensland, and a trained Aboriginal and Torres Strait Islander (A&TSI) health worker, I have a deep appreciation of health service failures and worsening health indicators experienced by Aboriginal and Torres Strait Islander people across the country.

Like most of my Aboriginal and Torres Strait Islander colleagues, I recognise that Aboriginal and Torres Strait Islander community-led and culturally safe primary health care services, strengthened by a well supported A&TSI health workers and practitiioners, are key variables in addressing the widening health gaps between Aboriginal and Torres Strait Islander people and non-Indigenous people in Australia.

Developing a culturally safe health workforce is heavily dependent on greater Aboriginal and Torres Strait Islander representation across all health professions. However, the particular availability of A&TSI health workers and health practitioners is, in many situations, instrumental to culturally safe health service delivery due to their cultural connections, professional positioning and scope of practice.

There is nothing new in saying that to achieve health equity for all in Australia requires much greater emphasis on preventive approaches delivered through increased investment in comprehensive primary health care. The Declaration of Alma-Ata identified the importance of this in 1978. In addition, this year’s Close the Gap Campaign report reaffirmed the relevance of targeted, needs-based primary health care in the pursuit of health equity for Aboriginal and Torres Strait Islander people. Importantly, the report highlighted the proven track record of Aboriginal community-controlled organisations in the provision of appropriate, culturally safe, effective and cost-efficient primary health care to Aboriginal and Torres Strait Islander people, and included evidence of the integral role that A&TSI health workers and health practitioners can have in primary health care service effectiveness.

In August 2018, Australia’s Health Ministers agreed to work with Aboriginal and Torres Strait Islander leaders to develop a much needed National Aboriginal and Torres Strait Islander Health and Medical Workforce Plan (the health plan). This commitment presents an important opportunity for the National Aboriginal and Torres Strait Islander Health Worker Association to table our workforce priorities and to persuade all relevant Aboriginal and Torres Strait Islander health sector colleagues and stakeholders of just how pivotal our unmatched workforce is to the delivery of culturally safe health care and, ultimately, to achieving health equity for Aboriginal and Torres Strait Islander people. Our workforce is able to do more with our cultural intellect and primary health care knowledge and skills, particularly through greater leveraging of our non-clinical primary health care capability, but workforce development barriers need to be addressed to better enable us to do so.

At the national level, there seems to be a genuine political appetite to engage with Aboriginal and Torres Strait Islander leaders to identify strategies for improving Aboriginal and Torres Strait Islander people’s health experiences and outcomes. Many of us felt and expressed immense pride and a renewed hope when, on 29 May 2019, Noongar man, Hon Ken Wyatt AM, MP, was sworn in as Minister for Indigenous Australians, the first Aboriginal person to take the cabinet portfolio. This, along with the Council of Australian Governments Health Ministers’ commitment to developing the health plan, and the recent signing of the historic Partnership Agreement on Closing the Gap, enabling Aboriginal and Torres Strait Islander people to have a direct say in and full ownership of the Closing the Gap framework for the first time, signalled new opportunities for Aboriginal and Torres Strait Islander people, including our workforce, to be genuinely included on matters affecting us.

We’re at the start gate but there is a reasonable level of optimism that these opportunities will support our voices being heard and understood. This also goes for the direct inclusion of A&TSI health worker and health practitioner workforce perspectives in deliberations planned ahead.

So, who are A&TSI health workers and health practitioners, and what do we do?

We are Aboriginal and Torres Strait Islander people working to provide a range of clinical and non-clinical primary health care services to our people and communities across the country. We make up the only Indigenous ethnic-based workforce in Australia, and likely the world, that has behind it a national training curriculum. A&TSI health workers and health practitioners are vocationally trained in comprehensive primary health care and are at the frontline, working autonomously or in multidisciplinary teams, providing access to culturally safe health care and services. We work across diverse geographic locations in any health care setting requiring our expertise, whether it be in a hospital, general practice or community setting. We provide holistic primary health care, including early intervention health checks and screening, health care treatment services, disease prevention and health and wellbeing education and promotion.

More often than not, A&TSI health workers and health practitioners have lived experience in and a deep understanding of the communities we serve, meaning we have cultural, social and linguistic knowledge and skills that set the workforce apart from other health professional groups. These skills underpin our community reach and engagement capability and, coupled with our comprehensive primary health care training foundations, enable our unique ability and perspectives as health care professionals, cultural brokers and health system navigators.

Put simply, we are connected to our communities and have the relevant cultural intellect to understand the social and cultural dynamics that need to be considered to gain respect and trust in shaping appropriate health care interactions. Highly relevant and sometimes very subtle dynamics, practices and protocols are easily missed or misunderstood by people from outside the community and can be potentially detrimental to safe and effective health service delivery. I draw on my own professional experience as an illustration.

When practising as an Aboriginal health worker, it was routine to apply my cultural intellect to support culturally safe health care delivery. One of my non-clinical roles was to conduct briefing sessions for new health practitioners and staff before they entered the community or a client’s home. New staff were informed that they would see and experience things in the community that would not necessarily accord with their own values and beliefs. They were advised to be aware of their biases, including unconscious bias, and to avoid passing judgement on the community or patient, as this would undermine trust and the community’s or patient’s sense of safety. Such loss of trust could result in loss of community respect and engagement and staff or service not being welcomed back. In certain communities, this outcome could be detrimental to health service access in the absence of alternative practitioners and services. My role as an Aboriginal health worker was instrumental in avoiding that outcome.

Throughout my career, I mentored other A&TSI health workers in ways to introduce new or visiting health professionals into community and homes. This involved first engaging with the community and/or patient to assess and confirm access arrangements. Circumstances would inevitably vary, with some people feeling more culturally safe, for example, meeting under a tree, which was their safe environment, while other people preferred not to see unfamiliar health staff at all. In such cases, my clinical skills were essential as I would communicate with the health staff, generally waiting in the car, for advice on what primary health care may be provided in the circumstances, then go back to the patient independently to deliver that care in a manner acceptable to the patient.

While our workforce has worked effectively for decades to improve the health experiences and outcomes of Aboriginal and Torres Strait Islander people, our work has been and remains under-recognised, undersupported and underutilised (here and here). Despite its ongoing professionalisation based on nationally recognised comprehensive primary health care training, health service models and priorities have limited the scope and reach of our roles. Available A&TSI health workers and health practitioners tend to be confined to clinical roles despite their often untapped potential to expand their scope to include health promotion and disease prevention activities. Greater exploration of roles that move beyond the clinical stream is required to support local community health needs.

These, and other barriers to improving our workforce utilisation and deployment such as wide-ranging role variation and fragmented health workforce planning, need to be addressed through nationally coordinated strategies. With Health Ministers agreeing to a workforce plan and a new national agreement for engaging Aboriginal and Torres Strait Islander leaders on the Closing the Gap framework, there is a window of opportunity to promote improved utilisation and recognition of our workforce. Our unparalleled roles and untapped potential, both clinical and non-clinical, must be recognised, valued and well resourced to promote culturally safe health care and to reduce service access barriers affecting Aboriginal and Torres Strait Islander people throughout the health care system.

Karl Briscoe is a Kuku Yalanji man from Mossman–Daintree area of Far North Queensland and current CEO of the National Aboriginal and Torres Strait Islander Health Worker Association. Karl has worked for over 15 years in government and non-government health roles including at the local, state and national levels.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.