Chips Mackinolty on Aboriginal health in the NT – small gains but a long way to go
Last night Warren Mundine proposed new military-style interventions into Aboriginal communities to provide health services. Chips Mackinolty shows that in the NT, community-controlled health services are the key to efficient and effective than health service provision.
This is a guest post by Chips Mackinolty that was first published, in edited form, in the NT News on 7 September 2013.
After more than 30 years in the Territory, Chips Mackinolty is taking a year off: for “a pre-pension gap year” as he describes it. After all, he says, “gap years are wasted on the young”.
Across most of that time he has worked for organisations which haven’t allowed him to have a public personal opinion. This has included working for Aboriginal organisations, writing as an interstate journalist for both Fairfax and Murdoch, designing for private enterprise clients, and even a stint as a Labor Party ministerial appointee. For the last four years he has worked for the Aboriginal Medical Services Alliance Northern Territory [AMSANT].
Apart from an irreverent political approach in his artwork, which has occasionally been touted by the NT News, Mackinolty has pretty much stayed out of the world of public opinion.
A day after quitting AMSANT, he writes an opinion piece for the NT News on an ongoing commitment: Aboriginal health. It is published on the day of the Federal election, but with no intent to influence votes. In his words, “that’s deliberate: whoever wins the election today must commit to the most successful bipartisan strategy in recent Territory history, closing the gap in Aboriginal health outcomes”. He tells a story that suggests that the Territory is hitting well above its weight.
But it’s not as simple as that, as he tells us.
Four or five years ago I made the decision to pretty much stop going to funerals. Of course since then I have been to many—too many. There came a time when it had got too much, with the vast majority of funerals for Aboriginal people. And the people were dying younger.
It was a difficult decision, for many were from the Katherine region. It might sound peculiar to readers, but Katherine was where I “grew up”. I got there in the early ’80s in my late 20s. An evening of fireworks for the third celebration of Self Government in Darwin then, bizarrely a day or so later for the final shoot in Mataranka of We of the never never with Aboriginal artists I then spent the next four years with.
But nevertheless it was a town, at that age, in which I “grew up”. Whatever I thought I had learnt on the streets of inner city Sydney were, frankly, SFA when it came to the Territory.
Most of that learning was with Aboriginal people across an area greater than Victoria: from Borroloola to Elliot; to Lajamanu and Kalkarindji and west to the Kimberley: Halls Creek, Kununurra and Wyndham. And then across via Timber Creek to Bulman, Numbulwar and Angurugu, south through Numbulwar to Ngukurr and back up through Jilkminggan, Barunga, Manyallaluk and Wugularr. It was an astonishing education in land, language and law. But it was a period I spent far too much time learning about death: the death of the artists I worked with, their families, and their children.
But I also learnt from whitefellas in Katherine: from the legendary Judy King and John Fletcher; from Francesca Merlan, Paul Josif, Mick Dodson and Toni Bauman, to Anne and John Shepherd and John O’Brien.
In different ways they, and many others, all taught me about living in the Territory.
In the late 1990s the CEO of the Jawoyn Association, the late Bangardi Lee, recruited me, Jawoyn woman Irene Fisher and Dr Ben Bartlett to put together a seemingly endless series of submissions that resulted—some years later—in the establishment of the Sunrise Health Service: an Aboriginal community controlled comprehensive primary health care service.
An Aboriginal community controlled comprehensive primary health care service? A bloody mouthful of a description, but nonetheless a symbol and practical evidence of what Aboriginal people and their supporters have achieved—and continue to achieve.
Across the NT, from remote clinics such as that run by the Pintupi Homelands Health Service to Danila Dilba in Darwin, the Aboriginal community controlled primary health sector serves roughly half our Aboriginal population, the rest through NT Government health services.
Over time, the process of privatising into the community controlled health sector will increase as services are devolved from government. It’s not been an easy process—and slower than many of us want. Nevertheless, it has had bipartisan support federally and locally for more than a decade. Famously, former CLP health minister Steve Dunham “rescued” the Sunrise Health Service in its early development stage when it met resistance from some health bureaucrats. His intervention saved what is now one of the NT’s great success stories.
The evidence, internationally, nationally and locally is that community controlled primary health care is more efficient and effective in delivering the goods.
According to recent data produced by COAG, the Northern Territory is the only jurisdiction in Australia on track to meet the closing the gap target of reducing the difference in life expectancy between Aboriginal and non-Aboriginal people. This is a good news story that has been barely reported in the NT outside the pages of this newspaper.
There are a number of reasons for this success. The last decade has seen a dramatic rise in hospital spending; more importantly greater resources have been distributed more equitably to the bush. The increased resources to primary health care through the Intervention, now known as Stronger Futures, has been a prime reason this has been possible.
But we are also doing it better—and in many instances better than anywhere else in the nation. For example, childhood immunisation rates in the community controlled sector is better than in many affluent suburbs down South.
And we are doing it smarter: led by the Aboriginal community controlled health sector, there has been an increased use of electronic data collection and analysis. Clinical Information Systems are used at the individual patient level to keep up-to-date, easily accessible health histories, as well as to alert clinicians to possible allergies, and efficiently prompt clinics to recall patients for regular checks as well as follow ups.
The data analysed can be tailored by individual health services, but all clinics in the NT now contribute the to Northern Territory Aboriginal Health Key Performance Indicators, which have a commonly shared set of clinical measures. Access to this data is strongly protected through privacy protocols.
The big picture of this is the capacity for these systems to allow for public health data to be analysed at a community and regional level, and for subsequent follow up. For example, a regular system of patient interaction through Child and Adult Health Checks has the capacity to identify “spikes” in particular conditions such as childhood and maternal anemia or otitis media in children.
This not only keeps an individual clinic alert to changes in local health, but also in ways to respond. This is achieved through a process called Continuous Quality Improvement [CQI], and is carried out by all clinicians at a service and the data collected is a key part of this process. For example, with otitis media it will guide individual treatment (are we always checking following the national guidelines? what evidence-based treatments are we giving? are we referring the patients to specialist diagnosis and care?), but also to the community as a whole (are we working with the council, school and families? what sort of other public health campaigns might we undertake?)
At regional level this data can be very powerful. As well as the regional Aboriginal Community Controlled Health Services we already have, such as Katherine West Health Board and the Sunrise Health Service, other regions are now working together through Clinical and Public Health Advisory Groups [CPHAGs]. The CPAHGS meet regularly and work cooperatively to share experiences and data, and ways to do things better. Some have identified particular regional health problems which would otherwise might be “lost” in large scale data bases.
The Northern Territory is the first jurisdiction in Australia in which all remote clinics now have electronic health records for their patients.
Further to this, our sector, along with government clinics, has pioneered the idea of a “shared electronic health record”. Over half the Aboriginal people in the NT have signed up to such a record, and we are in the process of readying the system so as to be part of a national network. This allows, with full permission from the patient or carer at every consultation to update their health record to a data base that can then be accessed by other clinics and hospitals. For example, a patient at Ngukurr may fall ill at another community, and get the appropriate treatment through their shared electronic health record. A hospitalisation will allow the clinicians to see someone’s record, know what medications they are on, and past conditions. After discharge from hospital, the health records are updated, and an electronic discharge summary is available to the home clinic.
These and many other innovations are behind the improved statistics—but there is a long way to go. It’s a welcome trend—but the good results will flatten out and perhaps reverse if we do not tackle the other social determinants of health. These include housing, education, early childhood development, substance abuse, food security, incarceration rates and social exclusion. It is reckoned that health services alone will only be able to deal with about 25 per cent of “the gap”: the rest is down to the other social determinants.
And that’s where governments of all stripes come in, and where the need for truly bipartisan approaches must prevail. Whatever the result of today’s election, Aboriginal health remains the Territory’s major challenge. Aboriginal children yet to be born will benefit if only our politicians are working, in the words of the AMSANT slogan, “together for our health”.