International Indigenous Health Conference 2014

Indigenous health agencies, groups and individuals from around the world are set to converge on northern Australia late this year for the inaugural 2014 International Indigenous Health Conference.

The Conference, which had its genesis in last year’s Australian National Indigenous Health Conference, aims to bring together more than 300 First Nations speakers and participants from across the globe to share experiences and ideas about how the close the health gap between Indigenous peoples and the wider community.

For the event’s organisers, for any such action to be successful it must involve a holistic approach embracing a person’s mind, body, soul and culture.

“This gathering will highlight some of the existing Indigenous health programs currently implemented in Aboriginal communities all over the world and provide a unique opportunity for delegates and speakers to see the power of people networking in one place, at one time, with similar goals,” the organisers said.

Community-based health programs will be a particular focus, with presentations from community groups to account for at least half of the conference’s proceedings.

The conference will be held at the Pullman Cairns International hotel, Cairns, from 15 to 17 December.

For further details, visit: http://www.indigenoushealth.net/submitpaper.htm

Health services for Aboriginal and Torres Strait Islander people: handle with care

This special Indigenous health issue of the MJA features stories of successful health care services and programs for Aboriginal and Torres Strait Islander people. As we seek to build on the wealth of experience outlined, it is worth considering what these contributions have to tell us about the characteristics and value of effective Indigenous health services.

It is more than 40 years since the founders of the first Aboriginal health service recognised a need for “decent, accessible health services for the swelling and largely medically uninsured Aboriginal population of Redfern [New South Wales]” (http://www.naccho.org.au/about-us/naccho-history#communitycontrol). There are now about 150 Aboriginal community controlled health services (ACCHSs) in Australia: services that arise in, and are controlled by, individual local communities, and deliver holistic, comprehensive and culturally appropriate health care. Panaretto and colleagues (doi: 10.5694/mja13.00005) describe how these services have led the way in high-quality primary care, as well as enriching both the community and the health workforce.

With the ACCHS model setting the standard, the values of responding to community need, Indigenous leadership, cultural safety, meticulous data gathering to guide improvement, social advocacy and streamlining access have gradually been adopted in other health care settings. The progress of the Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care (a Queensland Health-owned service also known as Inala Indigenous Health Service), is an example (doi: 10.5694/mja14.00766). Among the hallmarks of the service’s vitality are its ever-increasing patient numbers, research output, building of community capacity, expansion into specialist and outreach services and multidisciplinary educational role.

The East Arnhem Scabies Control Program, described by Lokuge and colleagues (doi: 10.5694/mja14.00172), is a dramatic example of innovation inspired by local need. This part of Australia has the highest rates of crusted scabies in the world, and the program involved collaboration between two external organisations, an ACCHS and the Northern Territory Department of Health. Importantly, it was able to be integrated into existing health services and largely delivered by local health workers, using active case finding, ongoing cycles of treatment and regular long-term follow-up.

Mainstream health services are now beginning to take the lead from Indigenous-specific ones. For example, the repeated observation that Indigenous men and women with acute coronary syndromes are missing out on interventions and are at risk of poor outcomes inspired a working group from the National Heart Foundation of Australia to develop a framework to ensure that every Indigenous patient has access to appropriate care (doi: 10.5694/mja12.11175). The framework includes clinical pathways led by Indigenous cardiac coordinators, and it is already producing results.

There is growing evidence for the value of sound and accessible primary care for Indigenous Australians. A letter by Coffey and colleagues (doi: 10.5694/mja14.00057) highlights the significant progress towards closing the mortality gap between Indigenous and non-Indigenous Australians in the NT since 2000, temporally associated with investment in primary health care. A research report from Thomas and colleagues shows that patients with diabetes living in remote communities were more likely to avoid hospital admission if they accessed regular care at one of the remote clinics, saving both lives and money (doi: 10.5694/mja13.11316).

While the diversity of health services and the evidence of effectiveness is indeed something to celebrate, it is a fragile success. In their editorial, Murphy and Reath (doi: 10.5694/mja14.00632) highlight the need for sustained, long-term financial investment in primary health care services for Indigenous Australians and the uncertainty arising from changes to health care funding and Indigenous programs announced in the recent federal Budget (http://nacchocommunique.com/category/close-the-gap-program). The detail of how funding will be reallocated with the “rationalisation” of Indigenous programs has not yet fully emerged. Analysis indicates the cuts over 5 years include $165.8 million to Indigenous health programs, which will be added to the Medical Research Future Fund. New spending on Indigenous programs includes $44 million in 2017–18 for health as part of the Department of the Prime Minister and Cabinet Budget (Adjunct Associate Professor Lesley Russell, Menzies Centre for Health Policy, University of Sydney, NSW, personal communication).

Changes to primary care funding are of particular concern. Knowing, as they do, the importance of removing barriers to access, there is increasing public discussion that ACCHSs and large Aboriginal medical services will not pass on the proposed $7 copayment to patients (http://theage.com.au/act-news/health-service-facing-budget-blackhole-by-not-charging-copayment–20140527-zrpb7.html). This will result in a decrease in funding to services that provide vital programs and deliver high-quality outcomes. The government has stated that everyone should share the deficit burden, yet the copayment has only been targeted at general practitioners and not specialist consultations. Is this fair and equitable?

It seems ironic that this threat to access and resourcing has arisen just as it is emerging that our investment in primary care for Indigenous Australians has been well made. In an Australia where many Aboriginal and Torres Strait Islander people still face significant socioeconomic and health disadvantage, the need for “decent, accessible health services” is greater than ever.

Racism, health and constitutional recognition

Constitutional recognition is the next step to building a healthier nation, says the Australian Indigenous Doctors’ Association

The impacts of racism are significant,1 they matter, and racism is rightfully acknowledged as a determinant of health for Indigenous populations worldwide.2 Recent research shows that experiences of racism and discrimination remain prevalent in Australia, through race-hate talk, race-based exclusion and physical attack.3 Correspondingly, there is evidence associating racism with poor outcomes in contemporary and historical contexts, via colonisation and oppression.4

From before birth, we are connected to family, community, culture and place. These interactions continue through life to form relationships which are crucial to belonging and to the construction of identity. This includes relationships with people and place, such as the actions and responses of others. Knowing about your own history and culture elucidates contemporary cultural ways of being, by providing a connection to the knowledge of ancestors. These connections are viewed as protective factors and contribute to building a strong sense of self and identity.5

Protective factors are inextricably linked to health and wellbeing, making the protection and promotion of culture critical to improvements in Aboriginal and Torres Strait Islander health. For Aboriginal and Torres Strait Islander people, our culture is a source of strength, resilience, happiness, identity and confidence. This philosophy embeds the importance of cultural safety into our daily practice. We do this because we know Aboriginal and Torres Strait Islander people are more likely to access, and will experience better outcomes from, services that are respectful and culturally safe.6

Thus, a focus of the work of the Australian Indigenous Doctors’ Association (AIDA) is promoting culturally safe learning environments for Indigenous doctors and medical students, and culturally safe service delivery to Indigenous patients. Cultural safety is about overcoming the cultural power imbalances of places, people and policies to contribute to improvements in Aboriginal and Torres Strait Islander health.7

We work within a strengths-based framework because conveying positive messages has the potential to make a significant contribution to changing public perceptions and attitudes.8 The media is, however, not bound to report in this way; it often focuses on stories of deficit. This type of reporting can fuel racist attitudes.8

Negative framing in the media weighs into current debates about the Racial Discrimination Act 1975 (Cwlth)9 and the debate about amending Australia’s constitution to recognise Aboriginal and Torres Strait Islander peoples as the First Australians.10 AIDA continues to support the maintenance of robust antiracial vilification laws as a necessary mechanism contributing to shape a health system that is culturally safe and respectful to all who access it.

Constitutional recognition is the next step in developing a healthier nation. Recognising Indigenous Australians as the First Nations peoples will enrich the identity of the nation and make significant steps towards reconciling past injustices. The current Constitution still provides a head of power that permits the Commonwealth Parliament to make laws that discriminate on the basis of race.10 The previous occasion on which protections under the Racial Discrimination Act were suspended was when activities were being implemented under the Northern Territory Emergency Response. At the time, AIDA advocated for the reinstatement of Section 9 of the Racial Discrimination Act, owing to the negative impacts that the suspension placed on the health and wellbeing of Aboriginal and Torres Strait Islander people in the Northern Territory.11 Recognising our rightful place as First Nations people in the constitution lays a strong foundation for the health, wellbeing and unity of all Australians. While it will not wash away the grave injustices of the past, with such recognition there is capacity to heal the deep wounds that affect health outcomes and continue to weigh heavily on Australia as a nation.

The medical community has a role to play in promoting Aboriginal and Torres Strait Islander recognition in the constitution. AIDA, as the peak body for Aboriginal and Torres Strait Islander doctors and medical students, will work with its peers in the medical community, as well as more broadly, to support this constitutional reform to achieve the sustainable, unifying and positive benefits that are envisaged for all Australians.

Indigenous health: radical hope or groundhog day?

Professor Ernest Hunter explains why learning from the past and investing strategically will have the best chance of success

In his book Radical hope: education and equality in Australia, Aboriginal lawyer, academic and land rights activist Noel Pearson contends:

Governments and their bureaucracies are informed by everything other than memory of what was done five years ago, ten years ago and eighteen years ago. Politics are remembered, policies are not.1

It also includes his 2004 Judith Wright Memorial Lecture, in which, reflecting on the political forces necessary to drive national change in Indigenous affairs, he notes:

it will take a prime minister in the mould of Tony Abbott to lead the nation to settle the “unfinished business” between settler Australians and the other people who are members of this nation: the Indigenous people.1

A decade on, Tony Abbott, as Prime Minister, delivered the Closing the Gap report.2 Having identified that his government’s new engagements will involve centralising responsibility for Commonwealth-funded programs in the Department of the Prime Minister and Cabinet, setting up the Prime Minister’s Indigenous Advisory Council and fostering linkages between bureaucrats, business and Indigenous leaders, he details mixed outcomes across four key areas — health, education, employment and safe communities. The outcomes were consistent with the Closing the Gap Clearinghouse report released a year earlier,3 which identified key high-level principles and practices characterising programs that worked: flexibility to meet local needs and contexts; community involvement and engagement; building trust and relationships; a well trained and resourced workforce; and continuity and coordination. Themes associated with less successful initiatives included: programs implemented in isolation; short-term funding and high staff turnover; lack of cultural safety; and inflexible program delivery. Similar issues emerged in a recent review of early childhood parenting, education and health intervention programs.4

Clinicians working in remote Australia will not be surprised. There have been health gains, but they are uneven: remote Indigenous Australia is clearly behind. Furthermore, it can be argued that for some conditions and in some areas the situation is worse despite significant clinical investments. For instance, when I began work as a psychiatrist in Cape York and the Torres Strait over 20 years ago, there were no mental health or substance misuse services. Now there are well over 100 workers across Queensland Health, Education Queensland, the Royal Flying Doctor Service, Medicare Locals, community-controlled services and Commonwealth-funded programs, plus contracted private clinicians. This does not include the dozens of residents trained variously in community and personal wellbeing, empowerment, mental health literacy, suicide prevention and more. Sadly, the situation in terms of mental illness is worse, probably reflecting both contemporary social contexts and delayed effects of neurodevelopmental adversity.5,6

Our understanding of the developmental determinants of chronic disease in Indigenous Australians has been evolving for more than half a century7 and there is accumulating evidence on childhood social factors increasing the risk of adult-onset mental disorders. For example, bereavement stress in mothers during the first years of life (particularly after suicide in the family) increases the risk of affective psychosis.8 Research on such topics involves controlling for potential confounders. In the real world of remote Indigenous communities, many children are exposed to serial adversity: pregnancies affected by high levels of stress; poor nutrition and inadequate antenatal care; prematurity; infant environmental instability and attachment difficulties; hospitalisation and other forms of separation from caregivers; bereavement stress; exposure to violence; early-onset substance misuse; and more. We can only presume that the consequences of such risk amplification will be substantial.

In 2006, soon after Pearson commended him, Tony Abbott called for a new form of “paternalism” that would be “based on competence rather than race” to address unrelenting Indigenous health problems associated with failed past policies such as self-determination.9 Now, he holds the reins. But whatever happens, the economic agenda will weigh heavily; Indigenous Australians will not be quarantined from budget cuts, changes to Medicare and welfare entitlements, privatisation, and the continuing feud between federal and state governments over health funding. In Queensland, public sector services (particularly population health and health promotion) sustained dramatic losses in the 2012–13 financial year that will be most consequential for remote Indigenous communities. Career public sector employees are giving way to locums, casual workers, agency nurses and project workers funded by non-government organisations. While this may bring new ideas, it risks losing domain knowledge and incremental improvement based on practice-based evidence.10

While there is no doubt that greater economic self-reliance will be critical to Indigenous futures, I believe that there is complacency regarding the flow-on effects of the contraction of federal and state public sectors for Indigenous health in remote Australia. Indeed, to support self-reliance in the long term, it is critical that we increase and sustain strategic investment in public health and clinical programs for pregnancy and early childhood to optimise neurodevelopmental potential. Is it “radical hope” to suppose that the new paternalism and new engagements will deliver? Or, as Pearson suggests in his chapter on cycles of policy reinvention in Indigenous affairs, will it be groundhog day?

Reports indicate that changes are needed to close the gap for Indigenous health

In reply: The letter from Coffey and colleagues helps make my case that a major role for Aboriginal community controlled health organisations (ACCHOs) in providing health care to Indigenous communities makes a real difference in the effectiveness and efficiency of service delivery. However, we cannot be certain that the progress made in reducing Indigenous mortality rates in the Northern Territory is the result of better health care; it may reflect improvements in the social determinants of health, such as education, housing and community violence.

Hospital data highlight that success is still a long way off. The ratio of Indigenous to non-Indigenous aged-standardised hospital separations for the NT is 7.9, compared with 2.5 for all jurisdictions.1 There is a clear relationship between the number of primary care visits and hospitalisation for Indigenous residents of the Territory who live in remote communities. For patients with diabetes, ischaemic heart disease and renal disease, around 22 to 30 primary care visits a year are needed to reduce hospitalisations to a minimum.2 That is why an increased role for ACCHOs is one of the keys to closing the gap.

Follow-up of Indigenous-specific health assessments – a socioecological analysis

Preventive health assessments have become a feature of health policies internationally.1 In Australia, Medicare-funded Indigenous-specific health assessments (herein referred to as “health assessment”) and follow-up items have been progressively introduced since 1999 as a means to improve the limited preventive health opportunities and reduce high rates of undetected risk factors among Aboriginal and Torres Strait Islander people (respectfully referred to hereafter as Indigenous people) (Box 1).3,4

A recent systematic review shows that while health assessments may increase new diagnoses, there is a lack of evidence of their effect on morbidity and mortality.1 While the reasons for lack of impact of health assessments are not well understood, it is clear that health assessments have limited potential to impact on health outcomes in the absence of appropriate follow-up care.5–7 The $805 million Indigenous Chronic Disease Package (ICDP) introduced by the Australian Government in 2010 included program funding and a new workforce to help increase the delivery of health assessments and appropriate follow-up.8

Analysis of Medicare data shows an increase in the uptake of health assessments, but relatively limited billing for Indigenous-specific follow-up items.5,9 The limited use of follow-up items raises questions about the effectiveness of health assessments as a catalyst for enhancing access to preventive care and chronic disease management,10,11 and highlights the need for further research on how to increase follow-up after a health assessment.12

This paper reports on patterns of uptake of health assessments and associated follow-up items, and examines the barriers and enablers to delivery and billing of follow-up care over the first 3 years of implementation of the ICDP.

Methods

The analysis presented here draws on the mixed-methods Sentinel Sites Evaluation (SSE) of the ICDP. SSE methods are detailed elsewhere.5 The SSE was a formative evaluation covering 24 urban, regional and remote locations in all Australian states and territories. Data were collected, analysed and reported in 6-monthly intervals over five evaluation cycles between 2010 and 2012.

Data on uptake of health assessments and follow-up items were derived from administrative billing data provided by the Department of Health from 1 May 2009 to 30 May 2012. The period May 2009 to April 2010 was used as a “baseline” period, as it preceded implementation of the ICDP. Health assessment data include Medicare Benefits Schedule (MBS) items, and are presented as health assessments claimed by services within the site boundaries per 100 Indigenous people aged ≥ 15 years. Similarly, the follow-up data include MBS items for follow-up of health assessments (see Box 1 for health assessment and follow-up items included in this analysis). Population data are based on Australian Bureau of Statistics projections from the 2006 Census according to the statistical boundaries used to define the sites.

Qualitative data on barriers and enablers to delivery of and billing for follow-up were obtained from individual and group interviews with a range of key informants from Aboriginal Health Services (AHSs), which include community controlled and government managed health services, and the general practice sector, which includes employees of Medicare Locals and general practices (Appendix 1). Interviewees were purposively sampled for their knowledge and experience with the ICDP. Interviews and analysis were informed by data on state of implementation of the ICDP at site level, as reflected in Department of Health reports. Repeated 6-monthly cycles of interviews and feedback of data between 1 November 2010 and 30 December 2012 allowed review and refinement of our understanding of delivery and billing of health assessments and follow-up items.

Community focus groups were conducted to explore community perceptions of accessibility and quality of services. Data from community focus groups were related to access to health services in general rather than being specific to follow-up of health assessments.

For the purposes of this paper, we conducted an analysis of SSE data using a socioecological framework.13,14 We reviewed the themes that were identified through the SSE as barriers and enablers to follow-up of health assessments,5 and used an iterative approach to categorise these themes according to various levels of influence: patient, patient–health service relationship, health service or organisation, community and policy environment. Some themes could be interpreted as a barrier or an enabler, and some were relevant to more than one level. We have therefore described each theme according to the predominant direction and most important level(s) of influence.

Ethics approval for the SSE was granted through the Department of Health Human Research Ethics Committee, project 10/2012.

Results

Of the 581 individual interviews done through the SSE, 63 contained specific information about the follow-up of health assessments. Of the 58 group interviews, 31 contained information relevant to this paper. These 31 group interviews included 103 participants. Of the 72 community focus groups, 69 provided data on access to services (Appendix 1).

Uptake of Indigenous-specific health assessments and follow-up Medicare items

Aggregated data show a general improvement in uptake of health assessments and follow-up items after the baseline period, with some differences in trends between the sentinel sites and the rest of Australia (Box 2 and Box 3). The uptake of follow-up items was disproportionately low compared with health assessments. There were marked differences in trends between individual sites (Box 4) — more marked than differences between sites according to rurality.5

Levels of influence

Barriers and enablers to delivery and billing of follow-up care using a socioecological framework were identified at five levels of influence: patient, interpersonal, health service, community and policy. Findings at each level of influence are summarised below and exemplar quotes illustrating each theme and sub-theme are provided in Appendix 2.

Patient level

Strategies to create community demand and incentives for patients to undergo health assessments were evident at the local level. These strategies did not appear to include attention to increasing follow-up of health assessments, and there was little evidence of patient demand for follow-up after health assessments in the sentinel sites overall. People working in ICDP-funded support roles with responsibility for encouraging patients to attend for follow-up reported that patients frequently appeared to lack information about the reasons for their follow-up referrals.

Interviewees in some sites identified relatively frequent movement of people, with no regular residential address and limited options for contacting patients by phone, as constraining follow-up care. Limited access to transport was consistently identified by community focus groups as a barrier to accessing services. Concerns were expressed about the cost of accessing follow-up services, with out-of-pocket costs to patients for allied health care in particular being unpredictable.

Interpersonal level

Negative past experiences affected patients’ willingness to attend follow-up appointments. Community focus groups and interviewees shared personal stories that reflected perceptions of racist attitudes among health service staff — commonly reception staff.

Outreach workers, funded through the ICDP, played a key role in educating and supporting allied health providers and clinicians to provide culturally appropriate care in isolated pockets, but overall, allied health professionals had relatively limited access to cultural awareness training. General practitioners and practice staff were reluctant to refer patients to allied health professionals who they could not be confident would act in a culturally appropriate way.

Some GPs reported reluctance to refer patients for follow-up unless critical because they believed the patient would not attend, or they provided referrals with no expectation of attendance. Some patients appeared to resist adherence to follow-up referrals and treatment due to what they regarded as the “pushy” nature and communication style of some health professionals, and lack of adequate explanation of their health problem and treatment needs.

External support by regional support organisations including Divisions of General Practice (and subsequently Medicare Locals) helped improve awareness of the Indigenous-specific follow-up item numbers in health services and among allied health providers.

Health service level

Health service providers felt that short consultation times meant they had limited opportunity to explain reasons for referral for follow-up care to patients. This was related in part to shortage of service providers, including GPs, allied health professionals, Aboriginal Health Workers (AHWs) and practice nurses. Limited numbers of allied health professionals in particular constrained referral for allied health services. In some settings, eligibility requirements meant that some AHWs appeared to be ineligible to bill for relevant follow-up services, constraining use of these item numbers.

Organisations tended to have a greater focus on health assessments — partly for financial reasons rather than potential health benefit — with less attention to follow-up. This imbalance was also evident at policy and patient levels. Small numbers of Indigenous patients in many general and allied health professional practices were associated with a reluctance to reorient systems to address the needs of relatively few patients.

A general orientation within some health services to acute rather than chronic illness care limited the availability and interest of many nurses in providing follow-up services. This was particularly the case in remote settings, where acute care skills are an important criterion in recruiting nurses. GP-centric models of care, lack of clarity about roles and lack of confidence in co-workers were associated with limited opportunities for practice nurses and AHWs to manage patient lists and appointments and deliver follow-up consultations.

Another constraint on the uptake of follow-up items was the lack of established systems to organise and bill for follow-up, and a perception that the steps required for completion and correct billing of follow-up services were complex and required highly organised patient records and information flow. The need for changed work patterns, reorientation to preventive health and enhanced staff training and support in the use of clinical information systems presented significant challenges to health services in delivering and claiming these Medicare items. Leadership and management were vital to system change: where leadership lacked commitment, management practices did not support system change to implement this aspect of the ICDP. Where GP-centric models of care were entrenched, it was particularly difficult to reorient systems to enhance uptake of follow-up items.

Lack of capability in using clinical information systems, such as patient recall and reminder systems, also constrained follow-up. Ineffective use of these systems to support patient care was commonly reported in AHSs and general practices, and was also evident in allied health professionals’ practice systems.

Staff turnover and use of locum staff (both nursing and GP) were associated with limited use of follow-up items. GPs were found to have varying knowledge and skills in relation to accessing appropriate Medicare items and working within a multidisciplinary team. Fluctuating staff numbers and variable knowledge among staff of the service operations made it difficult to reorganise systems to enhance follow-up.

Interviewees commonly reported that follow-up consultations were frequently billed as a standard consultation rather than the correct Indigenous-specific Medicare item number.

Lack of private allied health providers, and a tendency — for cost reasons — for clinicians to refer to salaried allied health professionals, where these professionals were available, also limited the use of the Medicare follow-up item numbers. Lack of easy access to information and transparency around gap payments, and entrenched perceptions that services would be expensive and require numerous repeat visits, were a barrier to health service staff referring patients to allied health professionals.

Community level

Barriers related to Indigenous social and economic disadvantage included poor availability of transport to attend follow-up appointments and high or unpredictable cost of allied health services. These were exacerbated in the context of general social and financial disadvantage. ICDP-funded outreach workers played an important role in helping patients overcome transport barriers in some sites.

Policy level

At the policy level, the relatively low value of the MBS reimbursement for follow-up (relative to health assessment), reflected in the large gap payments that patients are faced with, appears to be an important constraint to greater uptake of the financial incentives available for follow-up. Increased and ongoing funding to support preventive care through Medicare encouraged uptake of follow-up care. The impact of this was constrained by relative emphasis on health assessments. There was confusion over eligibility of AHWs to claim the use of the follow-up items. Funding of positions and programs (including through the ICDP) to assist with provision of information to providers and community members and to overcome barriers to access enabled uptake of follow-up items.

Discussion

While there has been a substantial increase in the uptake of health assessments over recent years, delivery of follow-up care and billing for Medicare Indigenous-specific follow-up items was disproportionately low, particularly given the evidence of the high levels of need for follow-up.6,12,15,16 Our study identified multiple influences on uptake of follow-up care at various levels of the system — many related to actual delivery of follow-up care and some related to billing for Medicare items numbers. The influences identified in our analysis are consistent with the research on barriers to implementing health assessments and on access to health services more generally.3,6,7,17–19 It appears that people receiving health assessments may be those who use health services more frequently,5 those of higher socioeconomic status, those with lower rates of morbidity and mortality and those with lower risk of chronic disease.1,20 Thus, health assessments may not be reaching those who need them most, reducing potential benefits at a population level. This “inverse care law”21 is likely to also be relevant to follow-up of health assessments, indicated by the access and cost barriers to follow-up identified in this analysis.

Strengths of the analysis in this paper include the mixed-methods approach, numbers and diversity of interviewees, geographic scope and diversity of study sites, and long-term repeated engagement with stakeholders, including feedback and member-checking of data and interpretation by local stakeholders. The socioecological analytical framework highlights that there are a number of factors at different levels of the system that enable or constrain choices made by individuals about access to health care.13,14

Limitations of this study include that sites were selected on the basis of early and relatively intense ICDP investment, and interviewees were selected because of their knowledge and interest in Indigenous health. The data provide a broad perspective of service settings across Australia, but this perspective may not necessarily be representative. Other limitations include that administrative data reflect billing for Medicare items, but do not necessarily accurately reflect the provision of clinical care. There is some evidence that follow-up may be happening, but that it is not being billed accurately. However, many of the identified barriers related to delivery of follow-up care rather than billing for follow-up items. Ecological models require themes to be categorised, and this process may be overly Western-centric.22 In conducting the analysis our team (which included Indigenous members) was sensitive to this risk. The strong links and interrelationships between themes need to be recognised. More general limitations of the SSE have been described elsewhere.5

Overcoming barriers to follow-up and strengthening enablers is vital to achieving health benefits from the large financial and human resource investment in health assessments. Our findings point to the need to support health services in developing systems and organisational capability to undertake follow-up of health assessments, but more importantly to reorient to high-quality, population-based and patient-centred chronic illness care. Drawing on our findings, we propose actions at various levels of the system to enhance both delivery of follow-up care and billing for follow-up items (Box 5). The diversity of contexts in which health services operate, the wide variation in current levels of follow-up between sites and the relevance of different contextual factors to barriers to uptake in different sites mean that strategies will need to be tailored to local circumstances.

1 Medicare Benefits Schedule (MBS)-rebated items for Indigenous-specific health assessments and follow-up2

Item characteristic

Health assessment

Follow-up by a PN or registered AHW

Follow-up by an allied health professional

Description

Available to all Indigenous people and may only be claimed by a general practitioner

After a health assessment, a follow-up item can be claimed by GPs for follow-up services delivered by a PN or registered AHW on behalf of the GP

After a health assessment, if the GP identifies a need for follow-up by an allied health professional, a referral is made and the allied health professional can claim this item

MBS item number

704, 706, 710 to 1 May 2010; thereafter 715

10987

81300–81360

MBS rebate

$208.10

$24.00

$52.95

Notes

Changed to simplify claiming by streamlining MBS item numbers to one item and making all claimable annually. This came into effect from May 2010 and coincided with implementation of the ICDP

Introduced in 2008, this MBS item allowed five follow-up services per patient per calendar year. This was expanded in 2009 to allow 10 follow-up services per patient per calendar year

Introduced in 2008, on referral from a GP, a maximum of five follow-up allied health services per patient per calendar can be claimed

AHW = Aboriginal Health Worker. ICDP = Indigenous Chronic Disease Package. PN = practice nurse.

2 Health assessments provided by a general practitioner, and follow-up services provided by a practice nurse (PN), registered Aboriginal Health Worker (AHW) or allied health professional

3 Follow-up services provided by a practice nurse (PN), registered Aboriginal Health Worker (AHW) or allied health professional in Indigenous people who had a health assessment

4 Uptake of practice nurse (PN), registered Aboriginal Health Worker (AHW) or allied health professional follow-up items in all urban sentinel sites and in the rest of urban Australia

NSW = New South Wales. Qld = Queensland. SA = South Australia. Vic = Victoria.

5 Potential strategies for strengthening follow-up of health assessments

Approaches to enhancing follow-up are presented for each level of the socioecological model. It is important that strategies to enhance follow-up use approaches across the range of levels, with attention to maximising synergies between approaches at different levels.

Patient level

develop locally relevant evidence-based approaches to create community demand for follow-up of adult health assessments;
address transport and other barriers to access to follow-up care; and
strengthen linkages between health services and local communities to enable recall of patients who require follow-up.

Interpersonal level

ensure that cultural awareness training reaches relevant providers, including allied health professionals and service support staff, such as receptionists.

Health service level

continue efforts to raise awareness of the follow-up Medicare Benefits Schedule (MBS) item numbers among health service staff and allied health professionals, including how item numbers complement each other and why the correct Indigenous-specific item numbers should be used (eg, additional numbers of items available with specific item numbers);
strengthen capability of health service staff to make effective and efficient use of clinical information systems, specifically including use of recall and reminder systems. Ongoing training and workforce development is required to address staff turnover and locum staff needs;
support service reorientation from models suited to acute care to models suited to patient-centred and long-term care;
develop and assess effectiveness and efficiency of alternate models of provision of allied health services and “what works for whom and in what circumstances”; and
identify and communicate cost implications of referral for follow-up care, and address cost barriers to follow-up care.

Community level

raise awareness of the need for ongoing chronic illness care and the importance of follow-up of issues identified in health assessments; and
identify relatively high-need and hard-to-reach groups in local communities, and develop strategies to overcome the barriers to these groups accessing follow-up care.

Policy level

clarify the Aboriginal Health Worker role in provision of services, including provider number eligibility;
ensure that the policy intent of having an Indigenous-specific MBS item number for follow-up services is clearly understood at different levels in the system; and
emphasise the health-relevance of health assessments and the importance of follow-up care, and refine incentives to maximise potential health gain.

Cost of best-practice primary care management of chronic disease in a remote Aboriginal community

The health of Australian Aboriginal and Torres Strait Islander people is very poor, and their access to primary care is inadequate, especially in remote areas.1–3 Prevalence of and mortality from type 2 diabetes (hereafter diabetes) and chronic kidney disease (CKD) are extremely high in remote Aboriginal communities in the Northern Territory.4 Chronic disease is responsible for 80% of the mortality gap between Indigenous and non-Indigenous Australians, with diabetes accounting for 12%.5 For all Indigenous Australians, the self-reported prevalence of diabetes is more than three times, and the incidence of end-stage CKD six times, the non-Indigenous rates.3 In remote Aboriginal communities in the NT, CKD prevalence is up to 25% of the population,4 or 46% of adults.6 Diabetes prevalence is in the order of 13%7 to 16%4 of the population, or up to 29% of adults.6 Both conditions are major contributors to cardiovascular disease, the greatest single contributor to the mortality gap.5

The origins of the chronic disease epidemic in Indigenous populations and, more broadly, the health gap are complex,3,6 and actions addressing both the social determinants of health3,4,7,8 and systematic primary clinical care6,9 are needed. In this study, we focused on the need for systematic clinical care, which is essential to reduce complications and delay the progression of diabetes and CKD.6,9

The rate of avoidable hospitalisations, a key marker of access to and effectiveness of primary care, is highest in remote communities.10 Australian and international evidence shows strong primary care systems result in better health outcomes, lower rates of avoidable hospitalisations, avoidance of dialysis, and significant cost savings.9–13 Many hospitalisations for complications of diabetes and CKD can be avoided through systematic primary care treatment, with significant medical cost savings.10,13–15 However, there are few estimates of the resources required to sustain primary care management of these conditions.

Particular difficulties for remote primary care include isolation, long distances to services, understaffing and a high turnover of clinical staff.16 Remote health care also requires special skills in chronic disease management, acute care, public health and intercultural communication.13,14,16,17

Our study was initiated by an Aboriginal community controlled remote health service because, despite its own perceptions of competent staff and clinical systems, staff still struggled to satisfy existing clinical protocols within given resources. The service received funding primarily from the then federal Office for Aboriginal and Torres Strait Islander Health and the then NT Department of Health and Families. Other sources included Medicare and a small university research grant. The aim of our study was to estimate the resources required by a remote health service to optimally manage diabetes and CKD — with adherence to the local Central Australian Rural Practitioners Association Standard Treatment Manual (CARPA STM) guidelines15 and with full population coverage.

Methods

The study took place between July 2010 and May 2011 in a remote Central Australian community. The methods were adapted from the models of care health service planning approach18 and an earlier NT cost study.10 Using the models of care approach, Segal and colleagues18 began with local best-practice protocols and estimated the staff time required to complete each of the recommended tasks for a given population. The population health status was assessed and the best-practice health care tasks required for that population were defined for each health profession involved. The time required per patient per year for each task was then determined, and the health care staffing resources then calculated for the population. Zhao and colleagues10 used an analogous approach to estimate the total operating costs of a “reasonably efficient” remote Aboriginal health service. Population needs were defined in terms of the CARPA STM protocols.15 The time estimate given in the definition of each linked Medicare Benefits Schedule item was used in quantifying the population’s staffing needs.10

The target population was resident adults (> 18 years of age) with diabetes or CKD. Best practice was defined in terms of the CARPA STM protocols.15 These protocols are used by all NT primary care providers: government clinics and Aboriginal community controlled health services.19 The tasks recommended by the CARPA STM include history taking, health promotion, education, physical examination, biochemical investigations and prescription of medication.15

First, prevalence of diabetes and CKD was estimated using the health service electronic health record, which represents not only patients presenting for diabetes and CKD management but also those identified in community screening. Prevalence at multiple levels of severity was estimated for both conditions. For CKD, levels of severity were stages 1–5 (estimated glomerular filtration rate range, > 90 [stage 1] to < 15 mL/min/1.73 m2 [stage 5]), with early CKD defined as stages 1–3. For diabetes, early was defined as non-insulin-treated and advanced was defined as insulin-treated. This enabled us to calculate, at the community level, the total annual number of diabetes and CKD care tasks recommended by the clinical protocols.

Second, semistructured interviews informed two aspects of the study. Clinicians were asked to estimate the time required for each protocol task, as well as any unremunerated out-of-hours time essential for the chronic disease management program. Clinicians’ descriptions of their role in chronic disease care helped to structure the final staff-funding model and also to identify other barriers to best-practice care.

Third, the daily work and chronic disease consultations undertaken by a cross-section of clinicians were directly observed in a detailed time-and-motion study. We measured the time taken by each clinician for each task defined by the relevant CARPA STM protocol. We then used a combination of these observations and interview data to estimate an average time for each item (such as measuring blood pressure or discussing diet). Supplies were itemised for each protocol and costed using the clinic’s supply orders or representative prices.

Fourth, financial records provided clinicians’ wage rates and administrative fixed costs. The wage rates, together with the estimates of time-per-task and annual community care requirements, were used to calculate the total cost of clinical staffing for primary care of diabetes and CKD.

We considered costs that, while non-clinical, are part of the overall cost footprint of diabetes and CKD care. Using data from direct observation of clinicians’ workdays, we estimated the proportion of total clinical time spent on diabetes and CKD. This proportion was then applied in a top-down fashion to the health service’s non-clinical costs, so that part of the cost of clerical staff and clinic vehicles was attributed to diabetes and CKD. These data collection and cost estimation methods are summarised in the Appendix.

Finally, we compared the estimated 2009–10 expenditure on diabetes and CKD with the projected annual expenditure using our best-practice model, reflecting full protocol compliance. For this, we assessed the level of clinicians’ adherence to the guidelines using the One21seventy health record audit tool, which is widely accepted in Indigenous health services in Australia and is based on the CARPA STM protocols.20 Per capita figures were calculated as total staff hours required for tasks specific to each group (eg, staff hours per patient per week to manage insulin treatment) divided by the number of patients with CKD or diabetes.

We distinguished between costs met out of the health service budget and expenses met directly by the federal and NT governments and other agencies. Examples of the latter are medications provided free to Indigenous patients under s 100 of the National Health Act 1953 (Cwlth), and visiting allied health services. The increased cost of such items in our model of care was separated from any additional funding needed by the health service to provide that model.

For comparison with the study by Zhao et al we adjusted the 2003–04 NT-wide figures for inflation occurring between financial years 2003–04 and 2009–10 (using the Consumer Price Index for health care in Darwin), and only included comparable aspects of our study (eg, insulin treatment was excluded).10,21

Approval was received from the remote community’s health board and the Central Australian Human Research Ethics Committee (ref: 2010.08.07). Written consent was obtained from all individual participants. Verbal and written feedback was provided to the health board at the conclusion of the study.

Results

In this remote community with a population of 542, 519 (96%) were Aboriginal.22 Of the 297 adults, 74 (25%) had diabetes and 86 (29%) had CKD; 45 (15%) had both conditions. Thirty-one adults (10%) had CKD stages 3–5. Of the 74 adults with diabetes, 13 (18%) were prescribed insulin.

The clinic was staffed by four Aboriginal health workers (AHWs), three remote area nurses (RANs), a general practitioner, a chronic disease educator (CDE) and an exercise physiologist. Twelve staff interviews were completed, and 14 workdays and seven clinical consultations were directly observed.

Quarterly chronic disease checks with an AHW or RAN were recommended for most patients with diabetes or CKD. A GP reviewed clinical findings and investigations, prescribed medication where necessary, and oversaw treatment planning. A full-time CDE educated individual patients and groups and managed insulin treatment. Interviewed staff identified education as crucial for patients’ control of their chronic disease. Locating patients in the community and delivering and explaining their medications were also a significant part of clinicians’ work. According to the medical record audit, 75% of all recommended protocol tasks for diabetes management and 79% for CKD were completed in 2009–10. Based on 2009–10 staffing, our model results in 29% of total clinical hours being used for diabetes and CKD care.

The total projected annual primary care cost of clinical management of diabetes and CKD management with full adherence to the protocols for all patients would be $900 792 (Box 1). On average, the annual cost per patient would be $7856, ranging from $4062 (for people with previously diagnosed early CKD without diabetes and without high cardiovascular risk) to $15 241 (for people with stage 5 CKD and advanced diabetes, with a recent diagnosis of either condition) (Box 2). Including only the costs met through the health service-allocated budget, the projected cost to the centre would be $645 313, or $5628 per patient on average, based on estimated total annual direct clinical staff hours specifically for diabetes and CKD of 4226 hours, or 2.37 full-time equivalents. (The difference between the cost to the centre and the total projected annual cost consists of costs met directly by other sources, including the federal and NT governments, rather than through the health service budget.) Expenditure in 2009–10 by the remote health service for diabetes and CKD care was estimated at $446 585, or $3895 per patient (Box 1). The health service would thus require an additional $198 728 (ie, an additional $1733 per patient) for best-practice management of diabetes and CKD. Overall funding received by the health centre in 2009–10 was $3413 per patient.

Interviews with staff identified a number of other barriers to optimal care. The high turnover of RANs necessitated frequent intensive orientation and teaching for new staff. The clinic was also rarely fully staffed. On-call night work, cross-cultural communication and cultural differences can present difficulties for RANs. AHWs may face a conflict of duties and values between the community and the health centre and a heavy responsibility in the role. A high acute caseload and the reticence of many patients to attend checks, for reasons including low health literacy and long waiting times, also hinder adequate management of chronic disease. There is a perceived need to allow more time for clinicians and patients to build relationships and for community-building work.

Discussion

Our study identified a high prevalence of diabetes and CKD in a remote community. As this is the community’s only clinic and the community health screening coverage is high, the clinic-based prevalence approximates population prevalence and is consistent with other remote community studies.4,13

This service is relatively well funded compared with other NT primary care services. Expenditure in 2009–10 was $3413 per capita per annum. The mean per capita figure for NT Government remote clinics for 2011–12 was $2329. This service has a higher than average compliance with the protocols for CKD and diabetes (77%, compared with the territory-wide figure of 73% for clinics participating in the One21Seventy audit). In response to low health literacy and patient mobility, the clinicians engage in very active outreach, health education and opportunistic screening. Most remote communities do not employ a CDE or exercise physiologist.

Despite these positive factors, 2009–10 expenditure was insufficient to provide optimal management by a margin of 44%, or an average of $1733 per patient with diabetes or CKD. Quantitative data were consistent with clinicians’ perceptions at interview that additional staff members were required to work with the CDE and AHWs to adequately meet community needs. Additional staff could increase the crucial quarantining of AHWs’ and RANs’ chronic disease care time from acute care time, possibly contributing to enhanced retention of staff. It would also allow greater allied health coverage, increasing exposure of patients to consistent health messages, and additional informal staff education.

The costs calculated in our study were higher than the inflation-adjusted (2003–04 to 2009–10) NT remote community estimates produced by Zhao et al.10,21 Possible reasons include the conservative estimates by Zhao et al of clinical time needed in remote health services for chronic disease care and staff training, and the higher administrative and salary costs at the studied remote clinic compared with those used in the earlier study.10

Strong primary care systems result in better health outcomes and significant cost savings.9,11–13 There is a strong argument for adequate funding of primary care services like the subject of our study. Our findings also highlight the lack of benchmarks that might indicate appropriate levels of funding to meet community needs and provide cost-effective care.

The strength of this study is its rigour and comprehensiveness, using multiple data sources (qualitative and quantitative). However, the methods are resource intensive and replication at other locations or with other disease groups would be expensive. Other limitations include the fact that costs were kept constant in our modelling. It is likely that unit and, possibly, fixed costs will increase as 100% community coverage and adherence to protocols is approached. It may be that 100% coverage and compliance is uneconomical.

Limitations to generalising these findings to other remote Indigenous health centres are the wide variation in transport costs, the availability of allied health care, and the feasibility of indicated insulin treatment given limited staffing resources. The small sample size also means that caution must be taken in generalising the results.

Nevertheless, this community is not unrepresentative of many remote Indigenous communities, and our study provides the best available evidence about the funding gaps for optimal management of two prevalent chronic diseases in such communities. It documents a significant shortfall even in a relatively well funded and effective primary care service, close to the regional centre. We would expect that the documented shortfall is a conservative estimate. These findings should inform funding bodies in their allocation of health resources for remote Indigenous communities. It may also be of use to this and other remote communities in advocating for their health care needs.

1 Estimated 2009–10 and projected annual costs* for the primary care management of type 2 diabetes and chronic kidney disease in a remote Aboriginal community

	Annual costs ($)
Category	2009–10	Projected

Remote health centre costs
Clinical staff	228 906	340 392
Remote area nurses and Aboriginal health workers	62 011	68 592
General practitioners	38 799	74 439
Chronic disease educators and visiting dietitians	128 096	197 362
Administrative staff	76 383	108 507
Medical supplies	4079	5795
Other operating costs	137 217	190 618
Maintenance	1240	1762
Vehicles	27 758	35 123
Other supplies	1635	2322
Other administrative (including computers, power)	106 584	151 411
Total	446 585	645 313
Direct costs to federal and NT governments†	234 424	255 479
Grand total	681 008	900 792

NT = Northern Territory. * Full coverage and full adherence to protocol. † Includes dental (NT), and optometry, non-vehicle and vehicle capital costs, and medications provided to Indigenous patients under s 100 of the National Health Act 1953 (federal).

2 Total projected annual costs per patient* for the primary care management of type 2 diabetes and chronic kidney disease (CKD) in a remote Aboriginal community, by stage of disease and comorbidity

	Cost, by severity of CKD ($)
Condition and case type	No CKD or stage 1–3	Stage 4	Stage 5†

CKD without diabetes
New cases	4345	4547	5200
Existing cases
Without high cardiovascular risk	4062	4175	5042
With high cardiovascular risk	4125	–	–
Non-insulin-treated diabetes
New cases	4428	4601	5252
Existing cases
Without high cardiovascular risk	4133	4228	5093
With high cardiovascular risk	4196	–	–
Insulin-treated diabetes
New cases	14 417	14 590	15 241
Existing cases
Without high cardiovascular risk	14 122	14 218	15 083
With high cardiovascular risk	14 185	–	–

* Full coverage and full adherence to protocol. † Dialysis costs excluded.

What can circle sentencing courts tell us about drug and alcohol problems affecting Aboriginal communities?

In New South Wales, circle sentencing courts take place outside of the courthouse, in a more informal community setting. The circle is made up of the magistrate, prosecutor, victim, offender (and his or her supporters), four respected Aboriginal Elders (who are significant to the offender), a representative of the support agencies and a lawyer from the Aboriginal Legal Service. The group talks about the impact of the crime on the victim and looks at the background of the offender and what caused him or her to get on the wrong path. The discussion can last up to 3 hours, after which the group develops a circle sentencing outcome plan, upon which all parties agree. The most important recommendations are made by the Elders. The outcome has to be acceptable to the magistrate. Nowra’s circle sentencing court has been operating for close to 12 years and the magistrate there has never yet disagreed with the Elders. The circle outcomes also need to suit the ability of offenders to comply with the conditions, as we don’t want them to fail.

How the circle relates to the Aboriginal traditional way of dealing with offenders

Up until the 1860s in the Shoalhaven region, we had a council of karadji men to administer tribal law. A locally known karadji man was Johnny Burriman. Keith Campbell wrote of him in the South Coast Register:

The work of Johnny Burriman to gain recognition for an important place for Aboriginal law in the Australian legal system failed, but the issue has remained. A significant step taken appropriately in the Shoalhaven district in recent years has been the introduction of circle sentencing.1

I believe this was a small but significant step towards recognition of the authority of a council of Elders, if not our traditional lore.

The Nowra circle sentencing court provides for sensitivity in reaching a sentence with as much compassion as the crime allows, but without frustrating Parliament’s intention. The justice carried out is a combination of criminal law and traditional values. Whereas the criminal justice system regards crime as something to be punished, Aboriginal people view it as something that requires healing. The regular courts have recently adopted a similar approach: their concept of it is therapeutic jurisprudence.2

How effective has it been?

The greatest achievements of the circle sentencing courts have been bringing down the barriers between the courts and the Aboriginal community, gaining mutual respect and also gaining a great deal of knowledge around the root causes of crime within Aboriginal communities, especially as it relates to alcohol and drug misuse.

The knowledge that has been obtained through open and honest dialogue between the Elders, the offenders and the victims could be regarded as revolutionary. Information is received “from the horse’s mouth” — from the people who have committed the crime, who are experiencing the disadvantages and suffering of alcohol and drug misuse. They are open and honest about it. Sometimes they break down and cry and volunteer insights about their lives. Some circle members even reveal information about themselves for the first time in their lives.

Aboriginal Elders effectively use the Koori way of obtaining comprehensive information from offenders, through the narrative form rather than questions and answers, as it is our cultural way of communicating. The Elders are also very clever in their use of shame: they make the offenders ashamed of their actions rather than of themselves. They say to an offender, “Be a proud Koori: you come from a good family and a rich culture, but you have got to be ashamed of your actions; this is bad”.

Understanding what underlies drug and alcohol problems

It is well known that the underlying causes of crime are unemployment, poor housing, poor education and poor health. As a result of the honest and open dialogue in each circle sentencing case, we have been able to identify some of the further underlying causes of this for Aboriginal people. We have discerned much self-depreciation, low confidence and low self-esteem, derived from 200 years of demonisation by the media and government and only learning about the negativity of Aboriginality. There is also direct trauma from sexual abuse, assault, other types of violence and racism. Being told you are lazy and good for nothing becomes a self-fulfilling prophecy over time. Additionally, there is indirect transgenerational trauma. Many of our offenders are from the Stolen Generations or are affected by family members who were. Aboriginal and Torres Strait Islander people who have been removed from their families often suffer feelings of abandonment and rejection. Their reactions take numerous forms, including anger, grief, loss of identity, alcohol and substance misuse, violence and other socially unacceptable behaviour, problems in relationships, psychological difficulties and isolation. Lack of identity can be linked to mental illness. As Aboriginal people operate on a collective or community level, the extended family is integral to the recovery process. Many often find themselves feeling caught between two worlds — their Koori heritage and the white world they grew up in. This can lead to a sense of not belonging, or feeling unwelcome in either world, with a crippling sense of isolation.

Problems like these need to be taken into account by the court system. This information does not supply the court with an excuse for an offence but it does supply an understanding of the root causes of crime, which is subsequently helpful in developing and delivering crime prevention programs. It is our belief that if clients have the opportunity to work on these problems, it gives them a chance to heal and not repeat the behaviour that led them to the court.

Often Aboriginal people use alcohol and drugs as an anaesthetic for the pain, fear and loss of cultural identity they are experiencing. The “dual diagnosis” which may result does not just refer to clients with hard-core drug problems and schizophrenia. It also refers to clients with a lifetime history of alcohol use disorder and coexisting mental or other drug disorder. The most common mental disorders among offenders with any drug use disorder are anxiety disorders. Some evidence of the intensity of this problem was provided in the 2009 NSW Young People in Custody Health Survey, which found, among other important and disturbing findings, that 92% of young Aboriginal people in custody had a psychological disorder and 83% were risky drinkers.3 Young Aboriginal people make up 49% of the juvenile population in custody.4 Drug and alcohol problems are not easy to overcome if you don’t know much about the causes. Service providers can learn more about the underlying causes of this problem and how to deal with them by participating in cultural awareness training.

After the circle — providing care

In circle sentencing courts, most offenders, and particularly those who commit the more serious offences, are people with a dual diagnosis. This is where the crime problem really becomes a health problem. To deal with it, Justice Health provides liaison nurses who work in courts and corrective services. We also have drug courts to deal with drug-addicted criminals. However, there still appears to be a problem in dealing with offenders with dual diagnosis, mainly because they don’t recognise or accept their illness. Within our Koori communities, there is a stigma around mental illness that leads to self-medicating with illicit drugs. There are also cultural barriers in accessing mental health services in NSW. Clients move between drug and alcohol and mental health services, and dual diagnosis clients are at risk of falling through the gaps. Most importantly, we need a model to promote community-based recovery rather than reliance on inpatient services, as Aboriginal people won’t remain away from their families for long periods of time.

Overcoming the root causes of drug and alcohol use and resultant crime

We need to develop wellbeing programs that focus on physical, psychological, spiritual and personal wellbeing, so that offenders are able to overcome their drug and alcohol dependency and move on to employment, housing, education and good health. We need to tackle the root of the problem if we are to break the cycle of welfare dependency and drug taking that ends in crime and despair.

In a circle, Elders can only direct offenders to do something about their problems; but these directions are taken seriously by the offenders because they are delivered by their respected Elders. However, Aboriginal and mainstream support services are needed to assist offenders to heal afterwards. Aboriginal organisations act as a link between clients and professional and mainstream services and are able to advocate, refer and liaise as necessary. But mainstream services can be limited by a lack of resources and training of support workers about the cultural and communication barriers that prevent them from working effectively with Aboriginal offenders. Some of our clients have experienced judgemental and patronising staff, including psychiatrists, psychologists, drug and alcohol counsellors and general health workers, who have lacked patience, empathy or cultural insight. Cultural bias still remains in the literature of psychology. We need culturally appropriate training for service providers — training that takes into account our differences in experiences, ways of communicating, values, kinship and families, along with insight into healing that recognises the impact of transgenerational trauma, our history and experiences on the current life situations of our people. At the end of the day, our clients have to access these mainstream services. If we fail in these areas, what good are all the efforts we put into getting our people to these services in the first place?

The need for additional support and training

I believe that the programs and training I am calling for represent the way forward. We need to train those who work in mainstream services to be competent when dealing with our people. In the criminal justice system, we are mostly dealing with Aboriginal people with very poor education who are often isolated from the rest of society. In the past, Aboriginal people were denied an education in Standard English and were only taught a modest amount of the English language, from which developed Aboriginal English. This language is still spoken frequently within Aboriginal communities. There is also the matter of poor health to contend with.

Although there is no one solution to the problem of crime, we have to try a combination of what is working in some areas. We need circles accompanied by cultural programs and specialist counsellors to help our people deal with dual diagnosis and trauma. Men’s group programs such as Red Dust Healing (http://www.thereddust.com) and Rekindling the Spirit (http://www.rekindlingthespirit.org.au) are very effective. The Waminda women’s organisation health and wellbeing program is also very effective for Aboriginal women.5 We need to promote pride in Aboriginal identity and culture, based on the belief that this is central to the health and wellbeing of our people and that knowing who you are as an Aboriginal person is central to any positive life. We also need to forge strong partnerships between organisations and agencies so that our clients don’t fall through the gaps.

Conclusion

When we lost our lore and important cultural and traditional way of life, we reached a point where we began to normalise abnormal behaviour such as substance misuse. This is not our traditional way. It is happening mainly because we have lost our structural system of learning and control. Circle sentencing operates on the understanding that the underlying causes of crime are often broader than a single incident and that they need the active participation of the whole community to fix them.

Circle sentencing highlights a need to develop effective cultural programs that educate our people about the positive aspects of our culture and Aboriginality and enable us to take pride in ourselves. These programs should improve the overall health standards of our people by promoting social and emotional wellbeing, acknowledging culture and identity as pivotal in reaching positive outcomes, and prioritising wellbeing as a vital foundation for belonging and identity. Service providers also need to be educated about Aboriginal communication styles, to ensure equality of access to justice and health services. Courts in NSW have developed a program to overcome this problem at a grassroots level, by employing Aboriginal client service specialists in local courts to service Aboriginal clients directly at the counter, in the registry and in the courtroom. Their most important and demanding task is interpreting court rulings. Only when all of these initiatives are put in place will the statistics on our people coming into contact with the criminal justice system begin to decrease.

Above all, the circle teaches us the need to recognise that the past still affects us today. The trauma and dispossession of colonisation compound the harmful effects on our health and culture. The summary statement of the International Symposium on the Social Determinants of Indigenous Health identified colonisation of Indigenous peoples as a central and undeniable causal factor in ill health.6 Colonisation has resulted in the decimation of much traditional Indigenous culture and customary practices, rituals and systems, particularly for Aboriginal people living in urban and regional areas (Mary Goslett, Masters student, Australian College of Applied Psychology, unpublished research paper).7

We are behind the eight ball when it comes to economic and social status. It is only very recently that our culture has begun to be celebrated and accepted to an extent that will assist our next generation to take pride in themselves as Aboriginal people of this country. Reconciliation is the way forward for us, but it will take time and a lot of effort on both sides to reconcile our differences. Circles, I believe, are reconciling our differences within the criminal justice system. Thoughtful and intelligent people from all walks of life will continue to make true reconciliation happen in this country.

International Indigenous Health Conference 2014

Indigenous health agencies, groups and individuals from around the world are set to converge on northern Australia late this year for the inaugural 2014 International Indigenous Health Conference.

For the event’s organisers, for any such action to be successful it must involve a holistic approach embracing a person’s mind, body, soul and culture.

Community-based health programs will be a particular focus, with presentations from community groups to account for at least half of the conference’s proceedings.

The conference will be held at the Pullman Cairns International hotel, Cairns, from 15 to 17 December.

For further details, visit: http://www.indigenoushealth.net/submitpaper.htm

Time to bust the myths on Aboriginal health

Decades spent caring for remote Indigenous communities on the wrong side of the nation’s infamous health gap has left 2014 AMA Indigenous Peoples’ Medical Scholarship winner, Wayne Ah-Sam, determined to bring health inequality to an end.

For almost 20 years, Mr Ah-Sam, a proud Kalkadoon/Gungangdji man, did what he could as an Aboriginal health worker to improve health and relieve suffering in far-flung communities across Australia’s Top End.

But, two years ago, Mr Ah-Sam realised a new approach was needed.

“I had seen a lot of health issues and inequality which have greatly impacted on our people’s health,” the father of four said.

“I felt that, as a health worker, I was only scratching the surface of a deep-rooted problem.

“I felt that I could do more to help my people’s plight, which forced me to make a decision – stay as a health worker, or maybe study medicine.”

Now in his second year of a Bachelor of Medicine degree at the University of Newcastle, Mr Ah-Sam believes that, as a doctor, he will be able to achieve much more to improve Aboriginal and Torres Strait Islander health.

“I want to be a voice for my people as I sit at the table with the policymakers to maybe influence or effect changes that have positive outcomes,” he said.

“There are a lot of negative stereotypes and myths about Aboriginal people and their health.

“Our health can be different and better, just by the changing attitudes, views and beliefs of the broader Australian community and the powers that be.”

Outgoing AMA President, Dr Steve Hambleton, presented Mr Ah-Sam with the AMA Indigenous Peoples’ Medical Scholarship, valued at $9000 for each year of study, in a ceremony at the AMA National Conference.

Dr Hambleton said the scholarship was designed to encourage and support Indigenous students who are preparing for careers in medicine, particularly those intending to work in Indigenous communities, and Mr Ah-Sam was a worthy recipient.

“The AMA understands and supports the unique contribution Indigenous health professionals and Aboriginal-controlled health services can make to close the gap and improve the health of Indigenous people,” Dr Hambleton said.

Mr Ah-Sam said he intended to “return home” once he finished his degree.

“I see myself returning to country and going to where I am needed the most – somewhere in an Indigenous remote community back home,” he said.

The scholarship was established in 1995 with a contribution from the Commonwealth Government.

Adrian Rollins