Towards a national primary health care strategy: fulfilling Aboriginal peoples aspirations to close the gap

The National Aboriginal Community Controlled Health Organisation (NACCHO) welcomes the Rudd Governments commitment to build a better primary health care system for all Australians through the development of Australia's first National Primary Health Care Strategy. In this submission we provide an important Introduction which sets the context and the definitions that underpin the recommendations for a national primary health care strategy that can best close the gap in life expectancy and health outcomes for Aboriginal peoples. The National Aboriginal Community Controlled Health Organisation believes that the success of a primary health care system should be judged by how effectively, those who are most needy are able to access quality care. The matter is not just about access per se, but also about who is accessing the health system. A strategy that supports health service provision to those who are already good users of the health system will not make gains in health outcomes for Aboriginal peoples. Access to primary health care is identified as a core obligation under the International Covenant for Economic Social and Cultural Rights (ICESCR). Within this core obligation is the understanding that Indigenous peoples have a right to design, deliver and control health services for them in order to achieve health gains. To this end, Australian Governments and non-government institutions have supported Aboriginal primary health care through Aboriginal Community Controlled Health Services (ACCHSs). The Rudd Governments definition of partnership means involving: "Indigenous people in the design and delivery of programs locally and regionally, and share responsibility for outcomes… This strategy is firmly based on the principle of working in partnership with the Aboriginal and Torres Strait Islander community-controlled health sector." The primary health care delivered by Aboriginal community-controlled health services is culturally appropriate because they are: 'An incorporated Aboriginal organisation, initiated by a local Aboriginal community, based in a local Aboriginal community, governed by an Aboriginal body which is elected by the local Aboriginal community, delivering a holistic and culturally appropriate health service to the community which controls it Services that are not Aboriginal community-controlled, by definition, cannot deliver culturally appropriate primary health care. However, services that are not Aboriginal community-controlled can be encouraged to deliver healthcare that is culturally secure. A definition and program prepared by the ACCHS sector for the delivery of Aboriginal cultural safety training for mainstream health services should be supported. NACCHO wishes to impart the message that the Strategy affirm the critical role and impact that accessible and culturally appropriate primary health care can make to close the gap in Aboriginal health standards by 2018 (Rudd Governments Statement of Intent), and for the Strategy to support the required actions needed to realise that objective. In this regard, NACCHO provides numerous recommendations under each of the 10 elements of the Discussion Paper: Towards a National Primary Health Care Strategy. Principal of these recommendations is that ACCHSs are the preferred service model in the delivery of comprehensive primary health care to Aboriginal peoples across Australia. Unless ACCHSs are supported as the key providers in a strategy to close the gap, through an appropriately resourced Capacity Building Plan, the disparities in Aboriginal people's health status will not be alleviated. A systematic framework for working towards a primary health care system for Aboriginal peoples that maximises local community control (such as through a national plan aligned with the Northern Territory Aboriginal Health Forum 'Pathways to Community Control'1) should underwrite a 5 year Capacity Building Plan for ACCHSs. Resourcing pathways to community control for primary health care services will require pooling of all Aboriginal–specific primary health care funds currently being directed to State Governments, Divisions of General Practice and other private health care providers. This will maximize the potential of primary health care to close the gap in life expectancy for Aboriginal peoples. Such fund pooling should be governed by an appropriate mechanism, requiring the involvement of, and endorsement by, the NACCHO Aboriginal leadership. Capacity building will require capital and recurrent funding and workforce strategies to train, recruit and retain staff including measures to address the vast salary disparities which currently prevent staff recruitment within ACCHSs. It will require resourcing based on the model of the Primary Health Care Access Program (PHCAP). A systematic approach towards defining the core deliverables for Aboriginal primary health care services (ie what funding would buy with an acceptable per capita benchmark funding allocation) is needed. ACCHSs funding should be based on a weighted population basis, according to need. A resource allocation formula that reflects the actual cost of ACCHSs providing the agreed core services at particular locations must be agreed to by NACCHO and Affiliates. Progressing such a Plan will require a formalised partnership between the Department of Health and Ageing and the NACCHO leadership, particularly in the form of a new National Framework Agreement. The expert advisory group is encouraged to read the full evidence-based NACCHO submission, but in summary, we draw attention to the following core requirements in order to expand ACCHSs: 1. A long-term plan of action for the expansion of ACCHSs developed in partnership between the Department of Health and Ageing and NACCHO and Affiliates (see Element 1), which meets specified targets and is measured by the indicators identified at the National Indigenous Health Equality Summit (2008) (Element 5). 2. Joint governance of an expansion program based on a National Framework Agreement (see Element 3). 3. The plan to support the adoption of core functions for ACCHSs across Australia (see Elements 2 & 10). 4. A workforce support program (see Elements 2, 8 & 9). 5. An evidence-based, ethical and acceptable quality assurance and performance management program developed by ACCHSs and for ACCHSs (see Elements 5 &6) 6. A funding base for ACCHSs that utilises: • funding on a weighted population basis according to need • pooling of all Aboriginal-specific primary health care funds (including those to State Governments, Divisions of General Practice and other private providers). See Element 10

Towards a national primary health care strategy: fulfilling Aboriginal peoples aspirations to close the gap

The National Aboriginal Community Controlled Health Organisation (NACCHO) welcomes the Rudd Governments commitment to build a better primary health care system for all Australians through the development of Australia's first National Primary Health Care Strategy. In this submission we provide an important Introduction which sets the context and the definitions that underpin the recommendations for a national primary health care strategy that can best close the gap in life expectancy and health outcomes for Aboriginal peoples. The National Aboriginal Community Controlled Health Organisation believes that the success of a primary health care system should be judged by how effectively, those who are most needy are able to access quality care. The matter is not just about access per se, but also about who is accessing the health system. A strategy that supports health service provision to those who are already good users of the health system will not make gains in health outcomes for Aboriginal peoples. Access to primary health care is identified as a core obligation under the International Covenant for Economic Social and Cultural Rights (ICESCR). Within this core obligation is the understanding that Indigenous peoples have a right to design, deliver and control health services for them in order to achieve health gains. To this end, Australian Governments and non-government institutions have supported Aboriginal primary health care through Aboriginal Community Controlled Health Services (ACCHSs). The Rudd Governments definition of partnership means involving: "Indigenous people in the design and delivery of programs locally and regionally, and share responsibility for outcomes… This strategy is firmly based on the principle of working in partnership with the Aboriginal and Torres Strait Islander community-controlled health sector." The primary health care delivered by Aboriginal community-controlled health services is culturally appropriate because they are: 'An incorporated Aboriginal organisation, initiated by a local Aboriginal community, based in a local Aboriginal community, governed by an Aboriginal body which is elected by the local Aboriginal community, delivering a holistic and culturally appropriate health service to the community which controls it Services that are not Aboriginal community-controlled, by definition, cannot deliver culturally appropriate primary health care. However, services that are not Aboriginal community-controlled can be encouraged to deliver healthcare that is culturally secure. A definition and program prepared by the ACCHS sector for the delivery of Aboriginal cultural safety training for mainstream health services should be supported. NACCHO wishes to impart the message that the Strategy affirm the critical role and impact that accessible and culturally appropriate primary health care can make to close the gap in Aboriginal health standards by 2018 (Rudd Governments Statement of Intent), and for the Strategy to support the required actions needed to realise that objective. In this regard, NACCHO provides numerous recommendations under each of the 10 elements of the Discussion Paper: Towards a National Primary Health Care Strategy. Principal of these recommendations is that ACCHSs are the preferred service model in the delivery of comprehensive primary health care to Aboriginal peoples across Australia. Unless ACCHSs are supported as the key providers in a strategy to close the gap, through an appropriately resourced Capacity Building Plan, the disparities in Aboriginal people's health status will not be alleviated. A systematic framework for working towards a primary health care system for Aboriginal peoples that maximises local community control (such as through a national plan aligned with the Northern Territory Aboriginal Health Forum 'Pathways to Community Control'1) should underwrite a 5 year Capacity Building Plan for ACCHSs. Resourcing pathways to community control for primary health care services will require pooling of all Aboriginal–specific primary health care funds currently being directed to State Governments, Divisions of General Practice and other private health care providers. This will maximize the potential of primary health care to close the gap in life expectancy for Aboriginal peoples. Such fund pooling should be governed by an appropriate mechanism, requiring the involvement of, and endorsement by, the NACCHO Aboriginal leadership. Capacity building will require capital and recurrent funding and workforce strategies to train, recruit and retain staff including measures to address the vast salary disparities which currently prevent staff recruitment within ACCHSs. It will require resourcing based on the model of the Primary Health Care Access Program (PHCAP). A systematic approach towards defining the core deliverables for Aboriginal primary health care services (ie what funding would buy with an acceptable per capita benchmark funding allocation) is needed. ACCHSs funding should be based on a weighted population basis, according to need. A resource allocation formula that reflects the actual cost of ACCHSs providing the agreed core services at particular locations must be agreed to by NACCHO and Affiliates. Progressing such a Plan will require a formalised partnership between the Department of Health and Ageing and the NACCHO leadership, particularly in the form of a new National Framework Agreement. The expert advisory group is encouraged to read the full evidence-based NACCHO submission, but in summary, we draw attention to the following core requirements in order to expand ACCHSs: 1. A long-term plan of action for the expansion of ACCHSs developed in partnership between the Department of Health and Ageing and NACCHO and Affiliates (see Element 1), which meets specified targets and is measured by the indicators identified at the National Indigenous Health Equality Summit (2008) (Element 5). 2. Joint governance of an expansion program based on a National Framework Agreement (see Element 3). 3. The plan to support the adoption of core functions for ACCHSs across Australia (see Elements 2 & 10). 4. A workforce support program (see Elements 2, 8 & 9). 5. An evidence-based, ethical and acceptable quality assurance and performance management program developed by ACCHSs and for ACCHSs (see Elements 5 &6) 6. A funding base for ACCHSs that utilises: • funding on a weighted population basis according to need • pooling of all Aboriginal-specific primary health care funds (including those to State Governments, Divisions of General Practice and other private providers). See Element 10

How to reform primary health care to close the gap

[Extract] Primary Health Networks were established in 2015 to reform the primary health-care system and better coordinate care across Australia. A range of services make up the primary care system in Australia. These include private general practices, community health centres within hospitals, and Aboriginal community-controlled health services. There are 31 primary health network boundaries across Australia, managed by a local board and funded by the Australian government. A core focus for primary health networks is to understand the health-care needs of their communities, identify service gaps and focus on patients at risk of poor health outcomes. Among the priority patient groups are Aboriginal peoples and Torres Strait Islanders. Recently, funding to primary health networks for ice and mental health programs was announced. This came with the expectation that primary health networks will work closely with Aboriginal community-controlled health services "to make sure we get those Indigenous treatment services right", according to the minister for rural health. The new Health Care Home trials will also involve Aboriginal health services. This requires primary health networks to collaborate with these services to build relevant patient health-care pathways. How can primary health networks work closely with these services

How to reform primary health care to close the gap

[Extract] Primary Health Networks were established in 2015 to reform the primary health-care system and better coordinate care across Australia. A range of services make up the primary care system in Australia. These include private general practices, community health centres within hospitals, and Aboriginal community-controlled health services. There are 31 primary health network boundaries across Australia, managed by a local board and funded by the Australian government. A core focus for primary health networks is to understand the health-care needs of their communities, identify service gaps and focus on patients at risk of poor health outcomes. Among the priority patient groups are Aboriginal peoples and Torres Strait Islanders. Recently, funding to primary health networks for ice and mental health programs was announced. This came with the expectation that primary health networks will work closely with Aboriginal community-controlled health services "to make sure we get those Indigenous treatment services right", according to the minister for rural health. The new Health Care Home trials will also involve Aboriginal health services. This requires primary health networks to collaborate with these services to build relevant patient health-care pathways. How can primary health networks work closely with these services

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

The National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people was conceived and started by NACCHO in 2001 and went on to be supported by the RACGP from 2002. The first edition was published in 2005 and has proven to be widely used by health services and health policy makers to inform best practice in preventing disease in Aboriginal and Torres Strait Islander populations. This second edition has been significantly updated and improved, with appraisal and endorsement from peak bodies across Australia. The National Guide is a practical resource intended for all health professionals delivering primary healthcare to Aboriginal and/or Torres Strait Islander people. Its purpose is to provide GPs and other health professionals with an accessible, user-friendly guide to best practice in preventive healthcare for Aboriginal and Torres Strait Islander patients. This second edition of the National Guide comprises: • the National Guide, which contains evidence statements, recommendations, risk calculation tables and an outline of the development of the guide • the evidence base: the collection of evidence underpinning the guide and recommendations (electronic only) (see the Methodology section ‘Searching the evidence base and drafting recommendations’) • a child and adult lifecycle summary chart listing activities recommended at each age group. The National Guide is available on the NACCHO and the RACGP websites at www. naccho.org.au and at www.racgp.org.au/aboriginalhealth/nationalguide. The National Guide is being integrated into clinical software over time to support primary healthcare professionals to implement best practice by providing them with accessible, accurate and up-to-date preventive health information relevant to Aboriginal and Torres Strait Islander people. For further information contact the RACGP National Faculty of Aboriginal and Torres Strait Islander Health on 03 8699 0499 or email [email protected]. Purpose: The National Guide is intended for all health professionals delivering primary healthcare to the Aboriginal and Torres Strait Islander population. This includes general practitioners (GPs), Aboriginal and Torres Strait Islander health workers, nurses and those specialists with a role in delivering primary healthcare. The National Guide makes specific recommendations regarding the elements of a preventive health assessment across the lifecycle of the Aboriginal and Torres Strait Islander population. The aim of the National Guide is to provide an up-to-date, evidence-based national resource that can help inform health providers and policy makers on a defined set of activities that are of particular relevance to Aboriginal and Torres Strait Islander people. These activities may prevent disease, detect early and unrecognised disease, and promote health in the Aboriginal and Torres Strait Islander population while allowing for variations based on regional and local circumstances. The health status of Torres Strait Islander people is very similar to that of the Aboriginal population, and the information in the National Guide can be applied to both population groups

Community based, multicenter, double-blind, randomised controlled trial comparing the effectiveness of topical ciprofloxacin and Sofradex as treatments for chronic suppurative otitis media in Aboriginal children

Many Aboriginal conmmunities in rural and remote western Australia have rates of chronic suppurative otitis media (CSOM) 10 times the rate that the World Health Organization deemed as a massive public health problem in the child population. The recognition by Aboriginal leaders that the treatment of CSOM is a priority area has led to this issue being highlighted in Australia's National Aboriginal Health Strategy. In Aboriginal children, the disease usually commences in infancy within a few weeks of birth, causes hearing loss, is recurrent, can persist into adulthood, and may impact adversely on child development. Our trial aimed to compare the effectiveness of topical ciprofloxacin (0.3%) and framycetin (0.5%), gramicidin, dexamethasone (FGD, Sofradex) as treatments for CSOM in Aboriginal children. The trial was the first conmmunity controlled, multicenter, double-blind, randomized, controlled trial in Aboriginal children across the north of Australia

Community based, multicenter, double-blind, randomised controlled trial comparing the effectiveness of topical ciprofloxacin and Sofradex as treatments for chronic suppurative otitis media in Aboriginal children

Many Aboriginal conmmunities in rural and remote western Australia have rates of chronic suppurative otitis media (CSOM) 10 times the rate that the World Health Organization deemed as a massive public health problem in the child population. The recognition by Aboriginal leaders that the treatment of CSOM is a priority area has led to this issue being highlighted in Australia's National Aboriginal Health Strategy. In Aboriginal children, the disease usually commences in infancy within a few weeks of birth, causes hearing loss, is recurrent, can persist into adulthood, and may impact adversely on child development. Our trial aimed to compare the effectiveness of topical ciprofloxacin (0.3%) and framycetin (0.5%), gramicidin, dexamethasone (FGD, Sofradex) as treatments for CSOM in Aboriginal children. The trial was the first conmmunity controlled, multicenter, double-blind, randomized, controlled trial in Aboriginal children across the north of Australia

Research methods of Talking About The Smokes: an International Tobacco Control Policy Evaluation Project study with Aboriginal and Torres Strait Islander Australians

Objective: To describe the research methods and baseline sample of the Talking About The Smokes (TATS) project.Design: The TATS project is a collaboration between research institutions and Aboriginal community-controlled health services (ACCHSs) and their state and national representative bodies. It is one of the studies within the International Tobacco Control Policy Evaluation Project, enabling national and international comparisons. It includes a prospective longitudinal study of Aboriginal and Torres Strait Islander smokers and recent ex-smokers; a survey of non-smokers; repeated cross-sectional surveys of ACCHS staff; and descriptions of the tobacco policies and practices at the ACCHSs. Community members completed face-to-face surveys; staff completed surveys on paper or online. We compared potential biases and the distribution of variables common to the main community baseline sample and unweighted and weighted results of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). The baseline survey (Wave 1) was conducted between April 2012 and October 2013.Setting and participants: 2522 Aboriginal and Torres Strait Islander people in 35 locations (the communities served by 34 ACCHSs and one community in the Torres Strait), and 645 staff in the ACCHSs.Main outcome measures: Sociodemographic and general health indicators, smoking status, number of cigarettes smoked per day and quit attempts.Results: The main community baseline sample closely matched the distribution of the Aboriginal and Torres Strait Islander population in the weighted NATSISS by age, sex, jurisdiction and remoteness. There were inconsistent differences in some sociodemographic factors between our sample and the NATSISS: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas. In both surveys, similar percentages of smokers reported having attempted to quit in the past year, and daily smokers reported similar numbers of cigarettes smoked per day.Conclusion: The TATS project provides a detailed and nationally representative description of Aboriginal and Torres Strait Islander smoking behaviour, attitudes, knowledge and exposure to tobacco control activities and policies, and their association with quitting

A chronic disease outreach program for Aboriginal communities

Background. Our objective is to describe a program to improve awareness and management of hypertension, renal disease, and diabetes in 3 remote Australian Aboriginal communities. Methods. The program espouses that regular integrated checks for chronic disease and their risk factors are essential elements of regular adult health care. Programs should be run by local health workers, following algorithms for testing and treatment, with backup, usually from a distance, from nurse coordinators. Constant evaluation is essential to develop community health profiles and adapt program structure. Results. Participation ranged from 65% to 100% of adults. Forty-one percent of women and 72% of men were current smokers. Body weight varied markedly by community. Although excessive in all, rates of chronic diseases also differed markedly among communities. Rates increased with age, but the greatest numbers of people with morbidities were middle age and young adults. Multiple morbidities were common by middle age. Hypertension and renal disease were early features, whereas diabetes was a variable and later manifestation of this integrated chronic disease syndrome. Adherence to testing and treatment protocols improved markedly over time. Substantial numbers of new diagnoses were made. Blood pressure improved in people in whom antihypertensive agents were started or increased. Components of a systematic activity plan became more clearly defined with time. Treatment of people in the community with the greatest disease burden posed a large additional workload. Lack of health workers and absenteeism were major impediments to productivity. Conclusion. We cannot generalize about body habitus, and chronic disease rates among Aboriginal adults. Pilot data are needed to plan resources based on the chronic disease burden in each community. Systematic screening is useful in identifying high-risk individuals, most at an early treatable stage. Community-based health profiles provide critical information for the development of rational health policy and needs-based health services

The protocol for the Be Our Ally Beat Smoking (BOABS) study, a randomised controlled trial of an intensive smoking cessation intervention in a remote Aboriginal Australian health care setting

Background: Australian Aboriginal peoples and Torres Strait Islanders (Indigenous Australians) smoke at much higher rates than non-Indigenous people and smoking is an important contributor to increased disease, hospital admissions and deaths in Indigenous Australian populations. Smoking cessation programs in Australia have not had the same impact on Indigenous smokers as on non-Indigenous smokers. This paper describes the protocol for a study that aims to test the efficacy of a locally-tailored, intensive, multidimensional smoking cessation program.\ud \ud Methods/Design: This study is a parallel, randomised, controlled trial. Participants are Aboriginal and Torres Strait Islander smokers aged 16 years and over, who are randomly allocated to a 'control' or 'intervention' group in a 2:1 ratio. Those assigned to the 'intervention' group receive smoking cessation counselling at face-to-face visits, weekly for the first four weeks, monthly to six months and two monthly to 12 months. They are also encouraged to attend a monthly smoking cessation support group. The 'control' group receive 'usual care' (i.e. they do not receive the smoking cessation program). Aboriginal researchers deliver the intervention, the goal of which is to help Aboriginal peoples and Torres Strait Islanders quit smoking. Data collection occurs at baseline (when they enrol) and at six and 12 months after enrolling. The primary outcome is self-reported smoking cessation with urinary cotinine confirmation at 12 months.\ud \ud Discussion: Stopping smoking has been described as the single most important individual change Aboriginal and Torres Strait Islander smokers could make to improve their health. Smoking cessation programs are a major priority in Aboriginal and Torres Strait Islander health and evidence for effective approaches is essential for policy development and resourcing. A range of strategies have been used to encourage Aboriginal peoples and Torres Strait Islanders to quit smoking however there have been few good quality studies that show what approaches work best. More evidence of strategies that could work more widely in Indigenous primary health care settings is needed if effective policy is to be developed and implemented. Our project will make an important contribution in this area.\ud \ud Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12608000604303