Close the Gap or Closing the Gap?

Today is National Close the Gap Day. A few months ago, there I was publicising it on Twitter, and I got into a conversation with someone critical of the campaign. They said it “raised money to promote government interference in Aboriginal communities.” I think the Close the Gap campaign and Closing the Gap were being thought of interchangeably.

I’ve seen confusion about this, both in social media and in real life, even among those who are quite involved in working in Aboriginal and Torres Strait Islander communities. (Alright, that was me. But I’m not the only one!)

So here is your cut out and keep guide (Warning – print off before attempting to do any cutting!) to Close the Gap and Closing the Gap.

Close the Gap

This is the campaign which started in 2008, responsible for the National Close the Gap days. It was kickstarted by the Social JusticeReport written by Tom Calma setting out a human rights based approach to health. A broad coalition of Aboriginal and Torres Strait Islander organisations and non-indigenous health and social care organisations worked together to promote and build support for the cause and set out how equity might be achieved. The Steering Committee is co-chaired by the Social Justice Commissioner, Mick Gooda, and the co-chair of the National Congress ofAustralias First Peoples, Jody Broun. You probably know Oxfam are involved, as they have been responsible for the campaigning expertise, but there are many other organisations involved, such as NACCHO, AIDA, the Healing Foundation, the AMA, the RACGP, ANTAR, even the NRL. You can see a full list here. Close the Gap an unprecedented coalition of support across many organisations. To date 185,000 people have pledged their support. You can do so too. (And you won’t find it asking for a donation, though you can buy some nifty merchandise!) You could argue that the campaign has been such a success that government used the same terminology!

Closing the Gap

This is the name given to a series of government programs with the aim of achieving indigenous equity. It has set 6 goals, not all of them health related, and each year at the opening of parliament the government makes a statement to parliament of progress on the goals. (The Close the Gap produce a parallel Shadow Report, and it’s worth reading both!) In the health arena, Closing the Gap is responsible for initiatives like the PracticeIncentives Program, the Closing the Gap PBS Co-payment to make prescriptions affordable, and measures to promote access to specialist and multidisciplinary medical care.

Why do I need to know this?

I’m biased, but I think it’s worth knowing this difference. The Close the Gap campaign is independent of government and is able to offer policy advice and criticise policy. As it is led by Aboriginal and Torres Strait Islander organisations it is able to represent what indigenous communities around Australia need to improve their health. The Campaign itself is not just a campaign, but models the ways of working in partnership for which it advocates. You can confidently support the campaign knowing that you are supporting Aboriginal and Torres Strait Islander people making decisions for themselves and taking leadership in health.

That’s not to say that Closing the Gap should not be supported. Seeing bipartisan support for one of the most important issues facing Australia today is not to be taken for granted, especially in the current political climate. There are some undoubtedly good things in the Closing the Gap measures, and the program certainly talks about working in partnership with Aboriginal and Torres Strait Islander communities, and I believe they do genuinely want to do so.

Looked at from an Aboriginal or Torres Strait Islander person’s perspective, though, government initiatives and commitments need to work hard to develop trust in communities. For over 200 years now, governments have been engaged in doing things to Aboriginal people, starting with massacresand missions and continuing with the forced removal of children from theirfamilies, which continued up to 1970. Every day in my clinical work, I am dealing with the consequences of this right now. It’s easy for non-indigenous people to think this is all in the past, but right now the Northern Territory Emergency Response, initially called the Northern Territory Intervention, is going on. Human Rights legislation had to be suspended to do this, and it is an action that has been widely criticised by Aboriginal communities across Australia and the UN Special Rapporteur on Human Rights.(PDF). For Aboriginal people, this is part of a continuing history of governments doing things to them. It’s worth noting in passing that this program is now called Closing the Gap in theNorthern Territory.

(Incidentally, for some insight into how policy is determined by its media coverage, read my Croakey post)

You can see the effect of this history, just by listening to what Aboriginal people are saying. For example in this paper about the care provided in Aboriginal Medical Services, there is a poignant exchange between Aboriginal health workers which speaks volumes about trust. 

In this poignant interaction between a board member (P1) and AHW (P2) both felt there was a hidden agenda to eliminate AMSs altogether, replacing them with poor quality ‘mainstream’ health care.

P1: They (government community health services) shouldn’t think that they are superior to the AMS team. That sort of an attitude, they should cut it out.

P2: That attitude will stay around for a long time until the boss of this organisation says something to them.

P1:They say that we need their services but that doesn’t mean they should come and tell us to do this, do this, do this… They try to bung low grade services onto us… If we look a little bit further down the track, say five or ten years, there won’t be any more AMSs. They will have become mainstream services.

P2: That’s a plan of the minister… low grade services.

The tweep I quoted at the beginning goes on to say “solutions to aboriginal health must prioritise stopping govt interference in family & community”

Close the Gap  is led Aboriginal and Torres Strait Islander organisations themselves with links back into communities across Australia. It has built a broad based coalition of support and is being listened to by governments. It is not responsible for the delivery of policy, but is able to set out what needs to be done to achieve health equity in a generation.

A final word – it is hard to remember, so here’s a handy mnemonic I made up: To remember the difference between Close the Gap and Closing the Gap, just think that the ING stands for In Government. Easy.

Now all you need to do is support the Close the Gap Campaign, sign the pledge and join an event today. It’s a cause that all Australians can support.

This blog's first scoop!

I have some news that you probably don't know. It's tucked away hidden in non-secret documents published in academic journals, which took literally minutes of hard work to discover. 

Aboriginal Medical Services are more effective than mainstream general practice!

To qualify that a bit - Aboriginal Community Controlled Health Services are at least as good, and maybe better at cardiovascular disease prevention than mainstream general practice.

So why isn't this widely known?

Let's start from here. If you were to right down what you know about Aboriginal and Torres Strait Islander Health (and you are a non-indigenous reader of this blog!) you would probably come up with words like Gap; poor health outcomes; non-compliance; difficult to reach; poor access; diabetes; renal disease; heart disease. You'll have others, too, many of them negative. If you do a similar exercise for "Aboriginal Medical Service" the most common reporting is of stories of dysfunction and poor governance.

Let me tell you how we know this unknown fact.

This is a paper from the Medical Journal of Australia in 2009, as part of the Kanyini Vascular collaboration. {Declarations - The service I work for is part of this collaboration and was one of the services audited for this paper. And one of the authors, David Peiris is a good friend of mine, who pointed out the comparison to me} They conducted a file audit of 1165 Aboriginal and Torres Strait Islander patients of Aboriginal Community Controlled Health Services to look at their management of cardiovascular risk in these services. The results are summarised in this graph:

Take some time to look at it. It shows for people with different levels of risk of cardiovascular disease (the different colours) which of their risk factors are being treated - blood pressure (BP), Cholesterol (statin), blood thinning (Antiplatelet - aspirin for most people) and combinations of these. The higher your risk, the more you benefit from having all of these treated.

What this graph shows is that there is plenty of room for improvement.

Now on to the second paper, the AUSHeart study from the same authors, who do the same sort of audit but this time for patients in mainstream general practice, and prospective. They included 5293 patients. The similar graph (sadly presented only in black and white!) is below.

We see a similar pattern, with similar risk levels. And again, room for improvement.

But when you compare the actual numbers (get a ruler and and the percentages - that's what I did!) you see that the Aboriginal Community Controlled Health services treat a higher proportion of their patients for their cardiovascular disease and their risk of cardiovascular risk. Let's put that into English. Aboriginal Medical Services are doing better at preventing thier patients from having heart attacks and strokes in the future. For those with established cardiovascular disease, about 60% of people with heart disease get the full recommended treatment in an AMS, and about 50% in mainstream practice. At each level of established and high risk disease, adequate treatment levels are higher. At low risk (where the blance of risk-benefit may be tilted more toward risk) fewer are treated.

This methodology is far from perfect. The differences may not be significant, we may not be comparing like with like. But the bottom line is this:

Aboriginal Community Controlled Health Services are at least as good as mainstream general practice in a common important aspect of preventive care in a population that we say is at higher risk and harder to reach and treat.

In other words, Aboriginal medical services are succeeding in providing quality care in communities that need it most, and other services struggle to reach.

It's early days in being able to quantify the quality of primary care in Australia, and this takes a purely medical model that would be narrower than that espoused by most Aboriginal Medical Services.

However, if you are a health professional, consider going to work in a setting where you are able to be truly effective. If you are interested in policy, then you need to look at the ACCHO sector at what mainstream primary care can learn. And if you are telling the stories of Aboriginal health, you may need to change from a story of unremitting failure, to one of success against the odds.

What the budget means for Indigenous health - a personal view

Our family sat down together  to watch the Budget the other night. (“Isn’t there anything else on?” asked one of my daughters. Would the politicians give them fewer nightmares than Doctor Who?) When it got the health parts of the budget, here is what I thought I heard Wayne Swan say: “Hospitals hospitals hospitals hospitals hospitals hospitals....”

I’ve skimmed over quite a bit of the budget coverage, but there isn’t a great deal of commentary on the parts of the budget affecting Aboriginal and Torres Strait Islander health. Croakey has a good summary and there was some good Twitter opinion.

However, I haven’t seen much other analysis more than just listing the components, but I think there are some implications that we need to watch for, so here, for what it’s worth, is my analysis. 

Insert disclaimer- I’m not an economist, just a practitioner enjoying trying to make sense of stuff. My analysis could be very wrong, (I don’t think it is, though!) but it’s a useful starting point for a discussion. This is also my opinion – I do work for some organisations who have official opinions on this, which may or may not coincide with mine!

Overall, the government has increased spending on Indigenous health – up from $1.032 billion to $1.074billion. The headline figure that the government has relating to Indigenous health is $5.2 billion, which is a lovely big sum of money. However, $3.4 billion over 10 years of this is for the Stronger Futures in the Northern Territory.  This also includes $6.4million (it actually says $6.4 but I don’t think that’s what it means!) for preserving AITSISIS collections and the money for SBS to set up a National Indigenous Free to Air TV service. (It’s not clear what happens to NITV). Also included in this sum are a number of projects in local Aboriginal and Torres Strait Islander communities, that all look very good. For people who don’t live in these communities though, there’s not a great deal , and there doesn’t seem to be an overall strategy.

Perhaps an overall strategy is to be found in the “Outcome 8” Indigenous Health documents from the Department of Health and Aging. This lists the budget under the Closing the Gap program around preventing chronic disease. It looks like these haven’t changed much. I don’t see any extra money or new initiatives there, but neither do I see a stripping out of money, which is good, given the context of this budget and the promise for a surplus.

There is also $67.9million dollars being cut from health workforce programs in "streamlining" workforce initiatives, with the money going to other government priorities. Given that the workforce dealing with Aboriginal and Torres Strait Islander health is somewhat understaffed, there could be a problem if there is not the workforce o deliver all these marvellous programs.

There is another pattern to be found in this budget, however. $75 million dollars have been removed from infrastructure projects in indigenous health. This has been redirected towards the Aboriginal and Torres Strait Islander Health program and the Health and Hospitals Fund. Given that  this latter fund includes $48.6million for indigenous health infrastructure in 10 remote communities, this looks like a funding cut to me. Apparently, DoHA say the money has been taken from low priority projects, though I don’t imagine they were low priority when the money was applied for or granted!

In a similar vein, money has been removed from indigenous literacy projects and redirected into Stronger Futures in the Northern Territory. While the right noises are made about primary care and education in the Stronger Futures initiatives, there is a significant amount of opposition to Stronger Futures in Aboriginal communities, because, once again, it continues the European tradition of doing to not working with. Stronger Futures started out as the Northern Territory Emergency Response, then became the Intervention, then became Closing the Gap in the NT and is now Stronger Futures. While the government have done more consulting around this, and there is a wide range of opinions in Aboriginal communities (as you would expect in any community) you could not argue that there was broad support for the measure in Aboriginal communities. The problem is that this will undermine the effectiveness of primary care initiatives and education initiatives done as part of this. There is clear evidence that real partnerships with Aboriginal communities are necessary to make progress in this area.

The other potential for a big narrative in this budget is in the measures for a National Disability Insurance Scheme, the Dental arrangements and the Aged Care measures. Aboriginal people have twice the rate of disability as non-indigenous people, and these disabilities occur at a younger age. There are also well recognised problems with oral health, which have knock on effects for diabetes and cardiovascular health. So these measures have great potential to provide support and much needed care for Aboriginal and Torres Strait Islander people. However, don’t forget that Aboriginal people have had much less access to Medicare and to the Pharmaceutical Benefits Program, and it has needed specific measures to address this. I see no reason why the National Disability Insurance Scheme would be any different with thought put to this. We will not Close the Gap if 10 years from now we have a lovely NDIS operating and Aboriginal people are accessing it at half the rate of non-indigenous people. This needs to be thought about at this stage.

So, I think the budget is a mixed bag for Indigenous Health. It’s worth checking out the media releases from some other organisations on their budget reaction, though, because I was surprised to find myself at the more negative end of the spectrum!

Here is what the National Congress of Australia’s FirstPeoples say

I've not seen a release from NACCHO’s yet, though these were tweets during the budget!

And here is what ANTaR have to say

So, as the AMA say, “the devil will be in the detail” and it is worth watching this space closely to see that this significant investment gets to where it is needed and is used in the most effective way. I have no doubt that that will involve partnerships with Aboriginal and Torres Strait Islander communities, rather than impositions.

I’m looking forward to the day when I hear a treasurer stand up to present the budget and hear them saying “Primary Care, Primary Care, Primary Care, Primary Care. Oh. And consultation. Real consultation.”

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Trying to be exciting about dull stuff – or a note about terminology!

Words are important. Sticks and stones might break bones, but words can certainly cause quite a bit of harm. So it’s worth just taking a moment to set out some of the thinking behind terminology I’ll be using on the blog, and my thinking behind it. Have you ever read a more boring blog sentence? Well, let’s see if we can make this a fun post. Or failing that, a short one.

The thinking behind what we call Aboriginal and Torres Strait Islander peoples has been heavily influenced by colonisation without us even noticing. Aboriginal is an English word which has come to mean the diverse group of peoples who are the original inhabitants of the land masses we now call mainland Australia and Tasmania. Torres Strait Islanders are the group of people who originally inhabited the islands between the northcoast of Queensland and Papua New Guinea. It’s intriguing that the name we’ve given references a Spanish explorer. I’ll try to write Aboriginal and Torres Strait Islander people when that’s what I mean. Much of the time I’ll write Aboriginal and I’ll mean to include Torres Strait Islanders too, really just for clear English purposes – which I am a bit sorry about, as should English trump the needs of Aboriginal and Torres Strait Islanders once again? I won’t be using the term Aborigine, as I find that dehumanising – it’s all too easy to forget we’re talking about people. And I won’t be using ATSI either, as abbreviations are usually a way of using jargon that allows us to forget the concepts behind the words.

I’ll use indigenous in the context of non-indigenous, meaning people who are not Aboriginal or Torres Strait Islander. I’ll also use indigenous when I want to talk about the indigenous people of other countries, as, for example, in the UN Declaration onthe Rights of Indigenous Peoples.

Other phrases it’s worth being clear on are AMS or Aboriginal Medical Service, which is a primary care service servicing predominantly Aboriginal and Torres Strait Islander people. An Aboriginal Community Controlled Heath Organisation (ACCHO), are essentially owned and run by their local communities. Not all AMSs are ACCHOs – Inala in Queensland is an example – and there are some ACCHOs which are not AMSs, providing social rather than health care. Often, the term Medical Service doesn’t do these organisations justice, as that is only a part of what they do, and they are much more than a doctor’s surgery that happens to see Aboriginal patients.

And, just to put a nice cap on all the confusion, there’s Close the Gap and Closing the Gap. Surely they must be the same thing? I’m afraid not. Closethe Gap is the campaign that you’ve heard of, kick-started by the then Social Justice Commissioner, Tom Calma, and supported by Oxfam and led by a range of Aboriginal organisations supported by a large number of non-indigenous health and reconciliation organisations. If you’re reading this, take a moment to sign the pledge, and think about joining or organising a morning tea for National Close the Gap day on March 22^nd.

Closing the Gap on the other hand, is the government program with 6 targets across a range of health, education, and social measures to, er, close the gap. Oh, it does get confusing.

So, that’s cleared that up, then. And with a hop and a skip we move on to the next post.

Initial thoughts on the Closing the Gap report

Each year the PM reports to parliament on progress against the Closing the Gap goals, and this year’s report has just been released. It’s not the most exciting read in the world, but it does highlight a lot of good work being done around the country. It seems we’re making progress in numeracy and literacy, pre-schools for 4 year olds and childhood mortality. The biggest problem, though, is the lack of good data, and without this it’s going to be really hard to tell how well we’re going.

If you want a more independent (and critical) review of progress towards the goals, as well as being shorter and easier to read you should go to the Close the Gap Steering Committee’s Shadow report.  Again, data issues are highlighted, but it explains much better the meaning of the statistics, and is much clearer on what needs to happen now. You wouldn’t know it from the PM’s report, but it’s actually an exciting time for Aboriginal leadership in health. The Indigenous Leadership Group of the Close the Gap Steering Committee is also now the National Health Leadership Forum of the National Congress of Australia’s First Peoples. It means that there is a real opportunity, if government wishes to make a real difference, of the plans to Close the Gap being developed by Aboriginal people. The government certainly makes the right noises on this in their report – it’s quite lovely to read these bits – but it’s worth remembering that there is still a whole big pile of mistrust over the continuation of the Northern Territory intervention among Aboriginal people, which is one of the reasons for anger (not riots) on Australia day.

Oh, and I should declare that I have represented the RACGP on the Close the Gap steering committee for about 18 months now, so of course I think their work is great!

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AMS Doctor - making sense of my work

Last week the Prime Minister, Julia Gillard, released the Closing the Gap report. She and Tony Abbott spoke to it in parliament. Everyone knows that there is large gap in health outcomes between Aboriginal and Torres Strait Islander people and non-indigenous Australians and this report sets out the progress against the goals in remedying this. In other (related) news, constitutional recognition of Aboriginal and Torres Strait Islander people is on the agenda, and there are good reasons why this will contribute to improved health outcomes for Aboriginal Australians. And, in a sign that this issue is important and hurting people right now, we have fresh in the memory a fairly peaceful protest reported as a riot on Australia day. Fortunately, most people agree that something needs to be done about this indigenous disadvantage. And this is where my fancy gets tickled! There is quite a lot of information out there about what works well (and what doesn’t) and quite a lot of opinion and policy. There are even places which collate much of this information in one place (see the award winning AustralianIndigenous Health Infonet which does a brilliant job of collating all the knowledge that’s worth knowing in this field.) But how do we make use of all this information so it can actually make things better for Aboriginal people across the country. I’m going to try to be a guide around all this knowledge. It’s not that I’m an expert, it’s just that I try to make sense of this to improve my own practice, and publishing this will help me do this. I will try to be the sort of guide that I enjoy most – knowledgeable, opinionated and occasionally entertaining. I hope. I shall try to distinguish between evidence and my opinions formed on the basis of that evidence. And I’m happy for contributions and discussion – none of us have all the answers, and so I will learn more than anyone. However, none of us will learn from abuse or personal attacks for opinions we disagree with, except that the attacker has just lost the argument. None of that here please.

My views are heavily influenced by the fact that I spend my primary job seeing patients. I think of this as an advantage (but then I would, wouldn’t I!) as too often people think they know what doctors are doing behind those closed doors, and get the policies wrong. I’ll reflect on my clinical work in an Aboriginal Community Controlled Health Service and the importance of Community Control. I’ll highlight research and reports that are published and comment on how it helps me improve what I do. And I’ll comment on the impact of policy on my patients and my consultations.

Because I’m a GP (not “just a GP” but a proud member of that specialty!) I’ll also highlight old and new GP philosophy and research that impact on my care – mainly because I can’t help myself!

A word of warning however. As a non-indigenous Australian, I will be fervently trying to avoid the mistake we non-indigenous Australians keep on making. We still have a tendency to put on a big red cape and wear our underpants outside our tights as we descend, briefly, on to an Aboriginal community with “The Answers.” The problem with this is that it just makes us look silly. Not just because that’s not where you should wear underpants, but because we’ve tried this as a solution, and it doesn’t work. It hasn’t worked for over 200 years now.

The only way these problems will be solved is to work with Aboriginal people and communities. Let me rephrase that. The only way these problems will be solved is to work with Aboriginal people and communities. So, one of the main reasons for writing this blog is that I’m a doctor, and I work in this field. That means people end up listening to what I have to say. And this is what I have to say, in essence: “You’re listening to the wrong person! Yes, I have some opinions, but you need to go and listen – not speak to, but listen, understand – to some people in your local Aboriginal community.” And that is essentially the central message of this blog. I’m optimistic that the gap will be closed, and excited by the nation that we can become. After all, get this right, and we will all be changed for the better.

Enough introductions now. Let’s see what shape this thing becomes...

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