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Discussion Paper for the Development of the National Aboriginal and Torres Strait Islander Health Plan

Key considerations and opportunities to improve health and wellbeing (continued)

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Opportunities within the health system

The health system has an important role to play in providing information to Aboriginal and Torres Strait Islander people on healthy lifestyles and treatment of diseases to support them to proactively manage their health. Opportunities and issues discussed in this section are not intended to limit consideration of other options.

Aboriginal and Torres Strait Islander people also have responsibilities to take action to live a healthy life and proactively manage their health conditions. Suggestions for the Health Plan on how to support an active partnership between Aboriginal and Torres Strait Islander people, health providers, and government and non-government agencies so that Indigenous Australians are in a strong position to manage their health are welcome.

Health promotion

Health promotion supports people to have control over their health. Health promotion includes activities such as changing cigarette packaging, providing information to support healthy lifestyles, and using social marketing and mass media advertising for example to encourage people to quit smoking and avoid drink driving.

There are significant opportunities for health gain through the use of health promotion approaches. Risk reduction or prevention approaches can reduce the risk of injury or disease, prevent or delay the development of disease among those at higher risk, minimise complications and improve health outcomes associated with both disease and injury. A population based approach must be taken to ensure that appropriate prevention activities occur across the continuum from wellness to ill health, for the overall population, specific sub groups and individuals at greater risk of harm. This whole-of-system approach shares the responsibility for health promotion across the health system.

Primary health care

Aboriginal and Torres Strait Islander people access primary health care services at a similar rate to other Australians. Several areas are working well, with most Aboriginal and Torres Strait Islander women attending antenatal care during pregnancy and most Indigenous children being immunised to prevent disease. Furthermore, since 2009 there have been increases in the number of services claimed through Medicare for health assessments and management of chronic diseases for Aboriginal and Torres Strait Islander peoples.

An area of concern is the early detection and treatment of disease, which is lower for Aboriginal and Torres Strait Islander people. For example, although Australian Indigenous people tend to have a rate of cancer similar to the rest of the population, they tend to be diagnosed later when the disease is more advanced and are less likely to receive treatment. The reasons for this may include lack of awareness of the role of primary health care services, how welcoming the services are to Aboriginal and Torres Strait Islander people, the relationship with the health care provider and trust in the provider, and communication issues including low health literacy.

Aboriginal Medical Services, including Aboriginal Community Controlled Health Services, play an important role in providing culturally competent, comprehensive primary health care. Aboriginal Medical Services are often Aboriginal and Torres Strait Islander people’s usual source of care in remote areas. Mainstream general practice is also a major source of primary health care for Aboriginal and Torres Strait Islander peoples, particularly in urban and regional areas.

Allied health care

The term ‘allied health’ is used to refer to a wide range of healthcare professionals who provide essential healthcare functions. Allied health care helps provide comprehensive health care, including in both primary health care and hospital settings.

Allied health professionals are an integral member of the interdisciplinary health care team and make a significant contribution to health care services for Aboriginal and Torres Strait Islander people. Allied health professional share in the delivery of health care services, including: services related to the identification, evaluation and prevention of disease and disorders; dietary and nutritional services; health promotion services; rehabilitation services; and health system management services.³³

Allied health care providers may include but are not limited to psychologists, dieticians, optometrists, physiotherapists, speech pathologists, audiologists, occupational therapists, podiatrists, pharmacists, radiographers, optometrists, mental health practitioners and social workers, amongst other health professionals.³⁴

Access to allied health care plays an important part in improving the quality of health and wellbeing for Aboriginal and Torres Strait Islander people, in particular for those who have more than one health condition. For example, a diabetic patient may need to see a podiatrist, a nutritionist, an eye specialist and a renal specialist to prevent or manage other health issues that can arise from their diabetes.Top of page

Specialised care

In cities, Aboriginal and Torres Strait Islander people are less likely to use private specialists than non-Indigenous Australians and in very remote areas this rate drops to half that of non-Indigenous Australians. There may be a range of reasons why this occurs including the high costs for these services, as fewer Aboriginal and Torres Strait Islander people have private health insurance, and the limited availability of specialist services in non-urban areas.

Access to coordinated and multidisciplinary care is essential to improve health outcomes for Aboriginal and Torres Strait Islander people. Care coordination can assist Aboriginal and Torres Strait Islander people, in need of specialist care, with access to the specialist, allied
health and other support services they need to manage their health effectively.

Dental care

Dental care helps maintain oral health and prevent potential health problems associated with poor oral health, including heart disease, low self-esteem, and impaired speech and language development.³⁵ Most dental care in Australia is provided by the private sector, and the waiting lists for public dental services are very long. Aboriginal medical services do provide dental services. National and state run programs, including the Australian Government’s $515 million package in the 2012 Budget to boost capacity of the dental workforce and reduce public dental waiting lists, are currently being rolled out.

Aboriginal and Torres Strait Islander people are less likely to receive preventative dental care and are more likely to have untreated dental disease (e.g. lost teeth and gum disease). Barriers to good oral health include the accessibility of oral health services, diet, water fluoridation, living conditions and the cost of dental care.

Integration

Lack of coordinated care for patients with complex health needs may mean patients miss out on specialised care as they move between health services provided by the local clinic, allied health, hospitals and specialised services.

The chronic disease management plans under the Care Coordination and Supplementary Services Program are a start to providing coordinated care for Aboriginal and Torres Strait Islander patients with complex care needs. Between 2009-10 and 2010-11, there has been an increase in Medicare claims for GP management plans from 23,972 to 32,717.

It is particularly important that mental health and social and emotional wellbeing services are integrated into programs given the associations between physical and mental health, poverty and disadvantage.

The integration of other services that address social determinants of health also need to be considered. For example, the schools sector is progressing reforms to work more closely with health professionals to assist in the early identification of issues that may impact on children’s learning and to support families to receive the assistance they require to help their children.Top of page

Mental Health, Social and Emotional Wellbeing

Social, historical and economic disadvantage is linked to grief, loss and trauma, poorer physical and mental health, high adult mortality and suicide, higher rates of contact with the criminal justice system, and child removals. In 2008, 8% of Aboriginal and Torres Strait Islander people aged 15 years and over had been removed from their natural family. The physical and mental health of Stolen Generations survivors and their descendants is generally worse than that of the broader Aboriginal and Torres Strait Islander population, with higher rates of unemployment and contact with the criminal justice system particularly evident.

For Aboriginal and Torres Strait Islander people, health is more than just the physical wellbeing of the individual – it also includes the social, emotional and cultural wellbeing of the person, their families and communities. The impacts of poor social and emotional wellbeing are borne out in Aboriginal and Torres Strait Islander peoples’ outcomes, with Indigenous Australians more than twice as likely to experience psychological distress and twice as likely to die from suicide as non-Indigenous Australians.

There are clear links between physical and mental health. Eight in ten (82%) of Aboriginal and Torres Strait Islander peoples who rated their health as excellent/very good in 2008 also reported feeling happy all/most of the time compared with 53% of people in fair/poor health.³⁶ Rates of psychiatric disability (including conditions like schizophrenia and personality disorders) were double that of other Australians.³⁷

There are also associations between culture and mental and physical health. The 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS), found that in remote areas, feeling happy was associated with cultural activities such as making or performing Indigenous arts.³⁸ Land is also essential to culture and its links with health, with Aboriginal and Torres Strait Islander peoples’ maintenance of close connections with ancestral country a prerequisite for good health. Significant and substantial health benefits are associated with greater participation in caring for country³⁹and with accessing homelands.⁴⁰

New advisory groups, such as the Aboriginal and Torres Strait Islander Mental Health Advisory Group and the Aboriginal and Torres Strait Islander Suicide Prevention Advisory Group, are helping ensure that the Australian Government hears from Aboriginal and Torres Strait Islander people and experts about these issues.

Drug and Alcohol Services

Excessive consumption of alcohol is associated with health and social problems in all populations. It is a major risk factor for conditions such as liver disease, pancreatitis, diabetes and some types of cancer, and can have a profound impact on foetal development if used by the mother during pregnancy. Alcohol is also a frequent contributor to motor vehicle accidents, falls, burns, and suicide. It has the potential to evoke anti-social behaviour, domestic violence and family breakdown.

There is also a link between poor social and emotional wellbeing and higher levels of alcohol and other substance use. Although Aboriginal and Torres Strait Islander people are more likely to not drink alcohol, a greater proportion of those who do drink consume alcohol at levels that pose risks for their health. Further, Indigenous Australians are four times as likely as other Australians to be hospitalised for conditions related to alcohol use, and more than twice as likely for conditions related to substance use. Reducing alcohol and other substance misuse can significantly reduce levels of violence and disability, as well as improving the overall health and wellbeing of a community.

There is now a greater understanding of how important it is to manage mental health and drug and alcohol use together. Staff in primary health care, mental health, and drug and alcohol services are being provided with the training and tools to better manage these conditions.

Hospitals

Hospitals provide life-saving treatments, booked or elective surgery and outpatient clinic services like antenatal classes. Some people are admitted to hospital as a patient after receiving treatment in an emergency department and some receive treatment without being formally admitted to hospital.⁴¹

Hospitalisation is becoming more common for Aboriginal and Torres Strait Islander people who are more likely to go to a hospital for treatment than non-Indigenous Australians. This may in part reflect improvements in personal identification of Indigenous status with the hospital data as well as better access to health care.

An area of concern is the potentially preventable hospitalisations which are five times higher for Aboriginal and Torres Strait Islander people than for other Australians. Many of these hospital admissions, most of which are for chronic conditions, could be prevented if more effective prevention or non-hospital care were available or accessible.

Post hospitalisation follow up care and coordination services are essential for Aboriginal and Torres Strait I slander patients who are at risk of experiencing otherwise avoidable (lengthy and/or frequent) hospital admissions; inappropriate use of services, such as hospital emergency presentations; not using community based services appropriately or at all; and who need help to overcome barriers to access services.

Although Aboriginal and Torres Strait Islander people are more likely to be hospitalised, they are less likely to receive a medical procedure or surgery while in hospital. The reasons for this lower rate of surgery are complex but may include financial barriers such as lower rates of access to private hospitals and private health insurance, patients having other health conditions which may affect surgery options, communication issues, preconceptions and discrimination.Top of page

Aged care

There is a range of services available for older people who require long-term support with basic daily living activities. The types of aged care services include residential (high care and low care), at home care and community support programs (including respite care). Aged care is often combined with basic medical services, preventative health services, rehabilitation or palliative care services.

Given the need to provide services for all Australians and the difficulties of service provision in remote areas there are limited options for older Aboriginal and Torres Strait Islander people. This is particularly relevant for those who would like to live in an aged care home designed specifically to support their culture. Aboriginal and Torres Strait Islander people will also have limited service options for staying in or near their community. The age for accessing home and community care programs has been adjusted to take account of the younger age at which Aboriginal and Torres Strait Islanders may begin to suffer from serious chronic illness.

Disability

Nationally, 50% of Aboriginal and Torres Strait Islander people aged 15 years and over had a disability or long-term health condition in 2008. Around one in twelve (8%) had a profound/severe core activity limitation.⁴² Physical restrictions were the most common type of disability reported in 2008, affecting one-third (33%) of all adults and 84% of those with a profound/severe core activity limitation. Nearly one in five people (17%) had a sight, hearing or speech disability. Disability is associated with higher rates of psychological distress and higher rates of multiple stressors compared with the non-disabled Aboriginal and Torres Strait Islander population.⁴³ People with disability or long-term health conditions were more than twice as likely to report high/very high levels of distress (43% compared with 19% of people without disability or long-term health conditions).⁴⁴

Multiple disadvantage can be experienced by people with disability. Aboriginal and Torres Strait Islander people with disability are more likely to live in poverty, to have fewer educational qualifications, to be out of work and experience inequality.

Health Workforce

The capacity to recruit and retain appropriate staff is essential to sustaining primary health care services for Aboriginal and Torres Strait Islander people, particularly in rural and remote areas.
Building Aboriginal and Torres Strait Islander health workforce capacity, across all levels of health (e.g. clinical, policy areas, administrative functions etc), is fundamental to enhancing the cultural competency of health services provided to Indigenous Australians. The ability to recruit and retain appropriate staff, who are responsive to the cultural needs of Aboriginal & Torres Strait Islander people, is also fundamental to the provision of sustainable primary health care services for Aboriginal and Torres Strait Islander people, particularly in rural and remote areas.

Although the number of Aboriginal and Torres Strait Islander people participating in the health workforce has been increasing, Indigenous Australians continue to be under-represented in the health workforce. It is therefore vital that the non-Indigenous and mainstream health workforce continues to be encouraged to work at all levels and in all areas of health service delivery for Aboriginal and Torres Strait Islander people. Similarly, non-Indigenous health professionals should be encouraged to work in health care services, particularly those services catering for Aboriginal and Torres Strait Islander people.

Collaboration and partnerships between all levels of government, the Aboriginal community controlled sector and non-government organisations across health, education, training, and employment are necessary to develop sustainable long-term health workforce solutions for both Indigenous and non-Indigenous health workers.

Access and Availability of services

Approximately a third of Aboriginal and Torres Strait Islander peoples live in major cities, under half in regional areas and a quarter in remote areas. Half of the people living in these remote areas are Aboriginal and Torres Strait Islander people.

Lack of availability of services in remote areas, distance and transport are the key reasons for not accessing doctors, hospitals, dentists and other health care providers when needed. In 2008, 26% of Aboriginal and Torres Strait Islander peoples aged 15 years and over reported problems with accessing health services. Access issues were higher in remote areas (36%) than non-remote areas (23%). Reasons for not accessing services vary between regions. In non-remote areas, waiting times and cost are important factors. In remote areas, the lack of available services and transport/distance are important factors.

The cultural competency of health services impacts on how Aboriginal and Torres Strait Islander peoples make decisions to use health services and their health outcomes. For example, if a patient has previously found health services uncomfortable, unwelcoming, or difficult to understand and navigate, this may lead to their avoiding the service in the future, which delays their seeking treatment.

Aboriginal and Torres Strait Islander peoples can also be supported to make informed choices about health and take active roles in bringing about change to environments that influence their health.

Aboriginal and Torres Strait Islander people continue to experience racism across multiple settings. According to recent research, approximately three out of four Aboriginal and Torres Strait Islander people report regularly experiencing race discrimination when accessing primary health care.⁴⁵

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33. Thomas, S, McLean, L, Debnam, A (2012) The Role of Allied Health in Health Care Reform NCMJ vol. 72, no. 5.
34. Ibid.
35. Australian Institute of Health and Welfare (2012). Dental health of Indigenous children in the Northern Territory: progress of the Closing the Gap Child Oral Health Program up to December 2011. Bulletin 102.
36. Australian Bureau of Statistics, 4704.0 - The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, cat. no. 4704.0, Oct 2010. (Life stressors - Adults)
37. Australian Institute of Health and Welfare, Mental Health Services in Australia, online publication. "Psychiatric Disability Support Services” pp4-5. (June 2012, accessed July 26 2012).
38. Australian Bureau of Statistics, 2010, The City and the Bush: Indigenous Wellbeing Across Remoteness Areas (cat no. 41020.0), in Australian Social Trends, September 2010.
39. Burgess, P., ‘Beyond the Mainstream: Health Gains in Remote Aboriginal Communities’, Australian Family Physician, 37(12) December 2008.
40. Australian Institute of Health and Welfare, 2011, Aboriginal and Torres Strait Islander Health Performance Framework 2010 Report: Detailed Analyses, Cat. No. IHW 53, Canberra.
41. Department of Health and Ageing (2010). The state of our Public Hospitals: June 2010 Report. Canberra: Commonwealth of Australia.
42. People were identified as having a profound or severe core-activity limitation if they required help or supervision for one or more core activities, such as self-care, mobility or communication.
43. Australian Bureau of Statistics, 4704.0 - The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, cat. no. 4704.0, Oct 2010. (Adult Health: Psychological Distress).
44. Australian Bureau of Statistics, 4704.0 - The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, cat. no. 4704.0, Oct 2010. (Life stressors - Adults).
45. Australian Human Rights Commission (2012), National Anti-Racism Partnership and Strategy Discussion Paper, p. 3.

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