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Cilento Oration 2011 - Indigenous Health care: Managing emerging challenges Print E-mail
The Quarterly 2011


The following is an abbreviated article from the transcript of Associate Professor Noel Hayman's 2011 Sir Raphael Cilento Oration presented to the Queensland members on Thursday the 19th of May at the Royal Children's Hospital Auditorium.

This presentation focuses on the complexity of Aboriginal health, prevalent diseases and the need for continuous health care quality improvement in Primary Health Care. As customary I would like to acknowledge the traditional owners, the Terrigal people on the North side, Jagga on the South, and our ancestors past and present.

Back in the 2006 Census, there were about 525,000 Aboriginal people living in Australia, 31% in the Northern Territory. Those 31% are pretty unique because two thirds lived in rural remote areas, whereas in Queensland only one third lives in rural remote areas. That is problematic when it comes to service delivery in the NT, especially when the population has been growing dramatically. Back in 1986 it was just over 200,000 today it is over 500,000. You cannot explain that population differential by natural growth alone. The biggest thing is identification; some researchers call it Ambilineal descent. When an Aboriginal person marries a non-Indigenous person, the children are more likely to identify as Indigenous. Also we have better counting methods and numeration with the census these days so this actually accounts for the increase in the population. The Aboriginal population is mainly young, with very few elders in our community. Actually my mum is 85 but there are very few Aboriginal women that live up to this age. Now my mother never drank or smoked. When I have done research in communities, I have always found that the older women did not drink or smoke, these days we have higher rates of smoking in young Aboriginal females.

My background is actually from the Stolen Generation. My grandfather, was Roy Smith, a Wakka Wakka, and my grandmother Daisy Smith, a Kalkadoon, when grandfather was about 12 years old he was put on Purga mission in the south east of Queensland. When my grandfather got an exemption certificate he left the mission and then went to live at Eidsvold. At that time they used to do spot checks to see how Aboriginal people were living and compile a report on the Aboriginals they conducted spot checks on. So if you didn't have a good report you were actually put back in the mission. I just brought that up to talk about the complexity of Aboriginal Health. Certainly Aboriginal culture is diversified, looking from my background to people in the NT, living very traditionally. You know, from the Kimberley to the Cape in far north Queensland; if you spoke to 10 Aboriginal doctors they will all have a different background. The complexity of Aboriginal culture is really problematic when it comes to delivering high quality services to Aboriginal people. What I might do at the Inala Primary Care (IPC), the general practise where I work as a clinical director, in the town of Inala, in Queensland, maybe completely irrelevant in places like NT, in small remote communities.

You know how you always hear the bad stories about Indigenous health? Well I want to tell you some good stories. I just want to give you some examples of the things we are doing at the Inala Community Health Centre, to improve the life expectancy of Aboriginal Australians. I am sure a lot of people have been out to the Inala Community Health Centre, but in case you have not it is a huge centre, near Brisbane, and it has a lot of services including: oral health, alcohol and drug services, diabetes education, mental health, breast screening and the Inala Primary Care (IPC) which used to be supported by Queensland Health before it become a private practice. When I first started working in the centre's general practise, 16 years ago, there were only 12 Aboriginal patients that nursing staff could identify. So I did some focus groups to see why Aboriginal people were not coming in. I started in 1995, and I have collected data now over the last 16 years.

One of the biggest things Aboriginal people pick up on is body language, they say "oh no, we just feel not welcome at this centre". They perceive staff as being unfriendly, as talking down to them, making them feel ashamed. On the other hand there was nothing in the centre that Aboriginal people could identify with. I actually did a focus group to talk to the patients and the first thing that came out was that there were no Aboriginals working at the centre. We then wrote a proposal and got some funding for an Aboriginal nurse and we got Nola. It has been the Noel and Nola team for the past 16 years and I am really proud and honoured to be working with an Aboriginal nurse and I believe providing high quality care to Aboriginal people in our area.

The patients also told us that the centre was really bland and that there was nothing there to identify with. Knowing that a lot of my patients are very good artists we had a local guy do a mural on the wall. If you go out to the Community Health Centre you will see a lot of indigenous art all through the centre, so now local people feel connected to the centre. In the first couple of years, both Nola and I conducted cultural awareness training, a mandatory requirement if you work for Queensland Health.

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We also found out that there was a lack of information about the centre's services so we put out pamphlets and disseminated these throughout the community. Based on the focus groups findings we put up strategies to improve indigenous access and we have been seeing increased numbers of indigenous patients. In the first year, when we had 12 patients, a patient would probably see a GP five times a year so we would have 100 to 200 patient-doctor consultations before intervention. After the first year we had 890 doctor consultations which were 5.7% of the total access to the Inala Health Centre General Practice, which is now IPC. Over the years it has actually grown dramatically and around 30% of all consultations done by doctors were actually to Indigenous patients. Which I think is a great achievement. Now we are doing about 1500 doctor consultations a month.

The other thing, which I am really proud of, is working with the Community Control Sector. Aboriginal people developed their own Community Control Sector because they perceived they were getting a bad deal. What I realised when I started working for Queensland Heath was that Queensland Health and the Community Control Sector never talked. Since we were trying to improve Aboriginal and Torres Strait health and me being an Aboriginal I felt like I had to break the water, so I actually went and talked to the Community sector about the things we could actually do together. It happened that at that time, 1994-95, the Community Control Sector was having problems doing sessions in local jails. I was invited to assist and during those sessions I came across patients that had been on the same medication for two years. They have Diabetes and have had HbA1C, the diabetes test, but being Aboriginal sometimes they do not make themselves known. It became obvious there was a need to improve health in correction facilities but the main outcome was the relationship building between the Community Control Sector and Queensland Health. Over the years, we conducted research and developed programs, such as Healthy for Life (which provides funding to improve the health of Aboriginal and Torres Strait Islander mothers, babies and children and people with chronic disease), it was a Commonwealth initiative, 104 million over three years.

Over the last three/four years I have collected data that showed that you can improve health outcomes by simply using continuous quality improvement. I do that with the Community Control Sector now and I have just started doing outreach to Cunnamulla, in south west Queensland, using the new Medical Outreach Specialist Program (MOSAP). Generally this entails a specialist from the city going solo to work with remote communities but the MOSAP I have, is called MOSAP ICD in Indigenous Chronic Disease. It focus on a team approach, so I take an Endocrinologist, myself, I have dual qualifications, I am a GP and also a Public Health Physician but when I go out there I wear my GP hat. We also take a nurse, a health worker and sometimes students for educational purposes. In the future we will be taking GP Health registrars, and we have decided to actually work in the Aboriginal Community Controlled Organisation out there. It is about empowerment, so when we go out there, we actually train the health workers. I take an administrator to teach them how to do administration and bulk billing, and so forth. It is very satisfying to see the results. We have looked at some diabetic patients who on first contact the average HbA1C was 9.7% and in six or seven months and we have already dropped it by one unit.

So, after fifteen years, what have we learnt?

Aboriginal people will come to a mainstream health service if you put in the right things. It is very important to go out there, get to know people and work with the elders. We have a great relationship with the elders and have a calendar which is distributed every year all around Australia. This year was actually based on some of our research. You probably know that a lot of Aboriginal people are sick and tired of our research in Aboriginal communities. But I think if Aboriginal people do it, it can be successful. It is about what works on the ground and what works at the interface, with the GP and patient.

The non-Indigenous doctors that I have been working with used to come up to me and say, "Oh boy, I'm seeing Aboriginal patients now, it's really great." They were getting an exchange of knowledge and patients were actually feeling a lot more comfortable. When I first started, if I went away a lot of Aboriginal people would not come in, but over the years, they have come to trust the other doctors. We now have great screening, early detection and high immunisation rates, probably about 93-94% for the last five years.

Now, my biggest problem is that we have mainstream health services actually turning away Aboriginal people because they do not have the staff to see them all. We had to ask Queensland Health for more money to invest in staff because we were soon seeing probably 40 or 50 patients a day. It was about acute management rather than chronic disease management. To our benefit there is a part of the Health Act called Section 19.2 where centres can actually bulk bill under that Act, and reinvest the money. Because IPC is under that act I can actually employ more doctors and nurses and we have been able to improve our staff numbers dramatically from access to bulk billing. We have come a long way since 1995 when it was just Nola and I to the 30 odd staff we have now.

We have done a couple of studies throughout the years but there is a study we did in 1998 worth mentioning. This was done on kids, we looked at a cohort, and we looked at birth, weight and smoking, back then we had a higher percentage of low birth weight babies in Queensland and huge exposure to cigarette smoking. We know now, with a lot of research going on, about low birth weight leading to the development of chronic disease in later life. So this is a big problem, but the thing is we go from low birth weight babies to obesity in our kids. In low birth weight babies' obesity rate increases with age, so that is a huge problem, particularly when the biggest risk factor for Diabetes is obesity. With the rates of obesity up in the Cape we are seeing 10 to 12 years olds developing Type II Diabetes. From my experience doing some study leave in Canada and looking at Aboriginal health over there they have already had that happen for quite a few years, so when I was over there I was seeing 20 year olds on renal dialysis and 20 and 30 something's actually having problems with eyesight because of Type 2 diabetes. Seeing that now in our Torres Strait Islander population is very concerning, the youngest Aboriginal guy I have seen was only 13 years old and he already had Type II Diabetes.

Are health checks really worthwhile?

If we look at health checks, which to me are underutilised in Aboriginal health, in 2006 and 2007, we had 28% coverage, meaning 80% of our patients actually received a health check. And if we look at the health check rate at 55, we got that up to nearly 70%. I am sure a lot of people know about Aboriginal heath checks, and there has been a lot of debate about if they are really worthwhile. They are expensive, $200 a pop, so if you do a health check, you get $200. Health checks were launched in 2004 because Aboriginal people did not have access to preventative medicine, so they decided to do these health checks to try to identify areas in which we can actually do preventative health assessments.

So what did we achieve with health checks? We analysed 413 health checks and found high prevalence for depression, alcohol and substance use, chlamydia, hypertension, diabetes, all the way down. We also looked at exercise and found that 31% did not do any exercise. So what are the outcomes? 82% had investigations ordered, 29% had a sexual health check and 27% of women had a pap smear undertaken at that health check. There were also a couple of breast cancers picked up by the female GPs at health check. So, what happened from that? Because we had high smoking rates, there was good advice given. The health checks are followed over time and we also do child health checks and we are going to follow those over time. We found that the smoking rate of 67% has dropped to 60% over the last three years, which is really pleasing. Also 49% have new medication, 42% received an immunisation and 29% had contraception arranged.

How do Aboriginal people rate their health?

We were curious to see how Aboriginal people self-rate their health and wanted to see what factors would influence that. We looked at the predictors of poor self-rated health assessments and there was no difference between male and female. Depression and smoking were high but the biggest one was actually waist circumference. A huge likelihood ratio, so the bigger waist circumference you had, the more likely you rated your health low. In summary, health checks are an effective tool for screening and implementing intervention. Incorporating health checks requires planning from the whole practice. Through the health checks we identified a huge burden of cardiovascular risk factors. There are quite a few sites across Australia, some indigenous, some non-Indigenous; we identify high risk and we offer them a polly pill which has got two blood pressure tablets, a stat and an aspirin. We are going to enrol those and follow them over time to see if we can decrease cardiovascular risk and increase adherence to medication, by taking one tablet instead of four.

Screening for Diabetic Retinopathy - What did we find?

We were concerned our patients would be referred to the hospital but they would never get seen. So a couple of doctor's did an advanced eye course; we actually bought a retina camera with the "Healthy for Life" money, taught the nurse how to take the photos and the doctors read them. We found there is a high rate of diabetic rotten retinopathy, even though 64% actually had good eyes. With this method when we refer a patient to the ophthalmologist, we really know they need to be seen. So we have taken the photo and it has been assessed. These days we have actually have a Heidelberg Spectralis, which is worth about 250 grand. Once it is identified on that machine, then it goes to this other machine and then the ophthalmologist knows exactly where to laser. Our aim is to use that machine to identify the issue and then the ophthalmologist will get their laser there, and it will be a one stop shop when it comes to Diabetic eye disease.

A Centre of Excellence in Indigenous Primary Health Care

It has been my vision over the last three years, to have a Centre of Excellence. I also want to bring out interns or medical post graduates, and teach them chronic disease management. We will be geared up to have GP registrars, Paediatricians and we are looking at having a Psychiatrist come into our new Centre, an Adolescent Psychiatrist too because some kids as young as eight are going to an enormous amount of funerals; parents, grandparents or aunties and uncles dying. There is a lot of grief and trauma to young indigenous kids growing up. Hence I was quite happy when Queensland Health came along and I was actually able to get seven million from them to start building the Centre of Excellence. It is going to be called the Southern Queensland Centre of Excellence in Indigenous Primary Health Care. The good thing is that they are not just providing the money to build it; they are also giving us some operational money. So starting June, July this year I will be up to 1.8 million to help fund that centre.

How can Health Administrators help to close the gap?

I would just like to talk briefly about the Cultural Security in the hospital system. Culturally secure services respectfully and effectively integrates the cultural values of Aboriginal and Torres Strait Islander people with best practice and service delivered by identifying elements of their culture that influence the delivery of health and community services. The National Health and Medical Research Council (NHMRC) has done some great work with cultural competency, it is about a set of behaviours and attitudes so that health services can work effectively across cultures. When we are talking about cultural competency we are talking about all cultures, but I like to separate it, to have that Aboriginal and Torres Strait Islander aspect to it. It is a sort of a self-testing cultural competency about awareness that makes you ask - Am I aware of culturally appropriate and inappropriate actions and attitudes? Does my behaviour and attitude reflect contentious vibes or a stereotypical mindset? These things are really important for doctors working in Aboriginal health and particularly in the hospital system, which is a huge system for Aboriginal people to navigate.

Also hospital data has been poor for many years; we are just starting to get a handle on it. I started teaching Aboriginal health back in the early '90s, at university, and we could only rely on data from Western Australia, Northern Territory and South Australia. Only those states had good quality, reliable data. In Queensland, we used to rely on our dogged communities, for data on mortality and morbidity for Aboriginal people, because there was no identification of Aboriginal people on death certificates until about 1997. I lobbied Ian Warner, who was our Aboriginal minister and a Labour minister in the early '90s, about identification on death certificates, because we were missing out on data. These days Queensland is actually not too bad in hospital data separation, we are included in national data statistics for Aboriginal people. The only states that are still lagging behind are Tasmania and the ACT. NSW having the biggest Aboriginal population has had a lot of problems, but their data is getting to a good enough quality to actually be aggregated with other States.

Thank you!

Assoc Prof Noel Hayman
Clinical Director of the Inala Indigenous Health Service in Brisbane and Associate Professor for the School of Medicine, Queensland University. Dr Hayman was named the Queensland Australian of the Year in recognition for almost two decades working to improve Indigenous Health.

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