Compared to their non-Indigenous counterparts, Indigenous Australians had lower use of preventive health services, higher rates of long and complex primary care consultations and a higher rate of potentially preventable hospitalisations, which may reflect poorer access to appropriate primary care services.7 In order to reduce these health inequities and improve Indigenous Australians' access to appropriate care, there is a need to strengthen and integrate primary healthcare, improve identification of Indigenous patients, improve health service delivery and resource allocation, ensure access to subsidised medication and provide a well trained and culturally safe health workforce.3,4,8–10
To achieve these goals, the Australian government provided funding for Indigenous health project officers and Aboriginal and Torres Strait Islander outreach workers to be employed within divisions of general practice.11,12 The purpose of these positions was to support primary healthcare providers in managing the unique health needs of their local Indigenous population and to improve collaboration between mainstream and Indigenous health services.11,12 These measures have the potential to increase Aboriginal and Torres Strait Islander peoples' trust and engagement with Australia's health system.13
This article presents an evaluation of qualitative data provided by divisions of general practice for the 2009–10 reporting period. It explores which activities were undertaken by divisions in order to improve Indigenous Australians' access to mainstream primary care, barriers or challenges identified by the divisions and the extent of collaboration between divisions, Indigenous services and local Indigenous communities.
Methods
Qualitative data were obtained from divisions of general practice 12 month reports for the 2009–10 reporting period. Division network members were required to report against a set of performance indicators linked to the objectives of the Australian Government Closing the Gap Initiative. It was each division's responsibility to ensure there were systems in place to collect and collate the necessary information and to comply with privacy and confidentiality regulations. Reports were submitted by divisions to the Australian General Practice Network (AGPN) through an online reporting system. The AGPN forwarded these reports to the Australian Government Department of Health and Ageing. Divisions had to address the performance indicators to an appropriate standard for reports to be approved. Once approved, the reports were made available for analysis by the Primary Health Care Research and Information Service (PHCRIS). Although PHCRIS is funded by the Department of Health and Ageing, it is an independent organisation and has no vested interests in the results of analyses.
All authors had full access to these data. Data was extracted for 112 divisions. Blank responses were received from 26 divisions who had not received specific funding for the Closing the Gap Initiative.
Qualitative data analysis was performed using NVivo 9 software. A grounded theory approach was used to code the data according to themes drawn from the Closing the Gap Initiative objectives and performance indicators. The two performance indicators that were used to establish the themes were: Indicator 1: Impact of activities and approaches used to address barriers to the use of mainstream primary healthcare services by Indigenous Australians, and Indicator 4: Impact of collaboration with local Indigenous services to address shared planning and priority setting. Data were coded by RK and OA according to the five key themes: general comments about Closing the Gap Initiative, barriers and enablers for access to mainstream care, activities and approaches to address identified barriers, collaboration with Indigenous services and community, and program challenges. Divisions' own words and terms were used to create labels for emerging subthemes. The data were initially examined by RK and OA independently, before discussing the themes and subthemes. Any differences in coding were resolved through discussion.
Ethics approval was not required for this study as the data were part of routine reporting requirements for divisions.
Results
Results are presented separately for each key theme. Direct quotes have been edited for typing errors.
General comments about the Closing the Gap Initiative
The majority of divisions provided positive comments regarding the Closing the Gap Initiative and were at various stages of implementing specific programs in order to improve access to primary care for Indigenous people. Many divisions felt that raising awareness about the initiative was of critical importance. In a number of divisions, this was successfully achieved among medical professionals and the general community through practice visits, seminars and informal meetings.
'A greater awareness around Closing the Gap measures has been obtained by systematically providing information to general practices via weekly communications.' [Division located in Western Australia (WA)]
Divisions commented that the Closing the Gap Initiative provided them with an opportunity to build and strengthen existing relationships with a range of stakeholders, which improved referral pathways for Indigenous patients and enabled the identification of service gaps.
'… the Closing the Gap program has opened up channels of communication between the divisions and key stakeholders and greatly facilitated the development of partnerships.' [Division located in New South Wales (NSW)]
Divisions established dedicated Closing the Gap committees and advisory groups to ensure effective coordination of the various planned and proposed activities. These groups included input from divisions, Aboriginal and Torres Strait Islander outreach workers, Indigenous health project officers, general practice, Indigenous health services and community representatives. Some divisions ensured that the Closing the Gap Initiative was included as a standard item on division meeting agendas to facilitate ongoing discussion.
'Closing the Gap Program Advisory Group established to guide programs and facilitate better links between practice staff, external organisations and Aboriginal community.' [Division located in WA]
Impact of activities and approaches used to address barriers to the use of mainstream primary care services by Indigenous Australians
The main barriers to access as identified by divisions and potential solutions that were put forward are presented in Table 1.
Table 1. Barriers and enablers to the use of mainstream primary care services by Indigenous Australians
| Theme | Barriers/challenges | Enablers/solutions | Supporting quotes |
|---|
| Financial |
Direct costs of consultations, medication
Lack of knowledge about bulkbilling practices
Lack of funding for Indigenous health programs |
Culture change: routinely offering bulk-billing to Indigenous Australians |
'One of the main inhibiting contributors for access was due to financial circumstance and the lack of "bulk-billing" services'
[Division located in Queensland] |
| Transport |
Inadequate public transport services
Poor timetabling
Health services not easily accessible by public transport |
Inexpensive and reliable transport options
Advertising of available transport services |
'[the division] has identified the disjointed links in urban Brisbane transport services'
[Division located in Queensland] |
| Cultural awareness |
Lack of cultural awareness and
sensitivity in mainstream care |
Provision of cultural safety training to practice staff |
'Strong need for cultural awareness training identified'
[Division located in Victoria] |
| Identification of Indigenous patients |
Practices unaware of number of Indigenous patients
Staff not confident asking patients about their Indigenous status
Indigenous Australians unwilling to self identify |
Encouraging Indigenous Australians to self identify through education and support
Reminding and prompting service providers to ask about Indigenous status |
'… self identification processes either did not exist or were limited to a question on a new patient questionnaire'
[Division located in Victoria] |
| Staffing issues |
Workforce shortages, particularly in rural and remote areas
Lack of Indigenous staff Inability to take on additional Closing the Gap work |
Employing and retaining more primary healthcare staff through targeted programs
Specific employment programs for Indigenous Australians |
'Workforce shortages and frequent
turnover of GPs and practice staff is
the main barrier to this initiative'
[Division located in Queensland] |
Activities undertaken to close the gap
All 86 divisions outlined the activities undertaken over the reporting period in order to improve Indigenous Australians' access to primary healthcare (Table 2).
Awareness raisingPractice visits
Newsletter articles
Website information
Formal and informal meetings'… practices visited by the Aboriginal health project officer to discuss the availability of bulk-billing and Indigenous PIP incentives'
[Division located in NSW]
Table 2. Closing the Gap activities undertaken by divisions of general practice
| Activity | Examples of actions | Supporting quotes |
|---|
| Distribution of resources |
Resources to facilitate uptake of Indigenous Medicare items, PIP and Indigenous status information collection
Directories of local Indigenous community services |
'… developing resources for general practices which will encourage self identification'
[Division located in NSW] |
| Cultural safety training |
Program planning and design
Workshops and seminars |
'… cultural safety training offered to all [division] staff'
[Division located in WA] |
| Improving practice environment |
Displaying Aboriginal flags and artwork
Changing operational structure: more bulk-billing, more flexible appointment systems |
'… commissioning of a mural to be completed by a local artist and young people with the aim of welcoming young Aboriginal people'
[Division located in NSW] |
| Indigenous staff |
Actively promoting the benefits of employing Indigenous staff
Positions actively advertised |
'… organisational recruitment strategies to employ and retain Aboriginal employees'
[Division located in NSW] |
Impact of collaboration with local Indigenous services to address shared planning and priority setting
The majority of divisions recognised the importance of fostering collaboration between mainstream primary healthcare providers and existing Indigenous service providers in order to improve continuity of care, share knowledge and decrease duplication of care. Collaboration also occurred with Elders and other Indigenous community members in order to take into account the specific needs of the local communities (Table 3).
TitTable 3. Collaboration activities undertaken by divisions of general practicele
| Activity | Examples of actions | Barriers | Direct quotes |
|---|
| Collaboration with local Indigenous services |
Collaboration on existing activities or projects
Collaborative planning of ongoing projects
Developing referral pathways
Building trusting relationships |
Concern about the lack of cooperation between agencies offering preventive health programs, leading to inefficiencies and duplication of services |
'A working relationship has been established with the Aboriginal health service and other services who work with the Aboriginal community and/or are involved in the Closing the Gap initiative'
[Division located in Victoria] |
| Collaboration with Indigenous communities |
Formal partnerships with community consultation groups
Inviting Indigenous Australians to join division advisory groups
Involvement of Indigenous Elders |
Difficulties in initiating collaboration
Ongoing problems related to lack of trust among Indigenous community members |
'… feedback from Indigenous representatives was positive, indicating a commitment to working with the division for the Closing the Gap Initiative'
[Division located in NSW] |
Closing the Gap Initiative difficulties and challenges
While the majority of divisions reported being satisfied with their progress with regard to the Closing the Gap Initiative, a small number of divisions highlighted some ongoing program difficulties and challenges.
Many divisions reported difficulties delivering cultural awareness training to practice staff due to time constraints, a lack of specific standards for such programs and delays in accreditation of programs by The Royal Australian College of General Practitioners (RACGP). While some divisions provided informal training sessions, many waited for RACGP approval.
'Cultural awareness training has yet to be conducted because the standards are yet to be released.' [Division located in NSW]
Related to the lack of cultural awareness training is the discomfort reported by practice staff in some divisions with regard to asking patients about their Indigenous status. These divisions expressed a desire for guidelines or similar documents that could be used to decrease the discomfort experienced by general practitioners and other staff. Some divisions reported practice staff did not understand why it was important to identify Indigenous patients in their practices, were unaware how many Indigenous patients attended their practices and believed there were no barriers preventing Indigenous Australians from accessing mainstream primary healthcare.
'Feedback from some staff has identified a level of discomfort with asking these questions.' [Division located in WA]
'… 64% of practices who responded to the survey said they did not feel there were barriers preventing Indigenous patients attending their practice.' [Division located in WA]
A small number of divisions cited the attitudes of practice staff toward the Closing the Gap Initiative as an important challenge. These divisions reported that staff were unwilling to make changes due to lack of interest or a belief that they did not have any Indigenous patients at their practice.
'There are challenges with attitudes from some practice staff who say they do not have Aboriginal or Torres Strait Islander patients and therefore see no need to adjust their systems.' [Division located in WA]
Discussion
The divisions identified a range of problems that Indigenous Australians encountered when accessing mainstream primary care, including financial barriers, transport issues and lack of cultural sensitivity. Similar barriers to access have been identified in previous studies and included lack of artwork and other items that created a welcoming environment, lack of Indigenous staff, practice inflexibility, lack of collaboration between service providers and reliance on short term and one-off projects.14–16
To address these gaps, divisions identified a number of projects and initiatives they had implemented or planned to implement. Divisions reported utilising Aboriginal and Torres Strait Islander outreach workers and Indigenous health project officers to coordinate these actions and improve the cultural acceptability of services for Indigenous Australians.11,14 Strong leadership has previously been identified as an important contributing factor to improving access to mainstream health services.16
Awareness raising among service providers and the local Indigenous community was undertaken by the majority of divisions and involved practice visits, dissemination of information and regular communication. Other activities undertaken by divisions included making changes to the practice environment to improve cultural acceptability, encouraging bulk-billing and increasing awareness regarding local Indigenous health issues. Offering bulk-billing to Indigenous patients, adequate resourcing, respect for language and culture and sound understanding of the complex issues surrounding Indigenous health have previously been highlighted as crucial to the success of Indigenous health projects and initiatives.14–16
Few divisions mentioned specific initiatives to encourage Indigenous people to pursue careers in primary healthcare. Specific programs included training programs for medical receptionists and a commitment to encouraging applications from individuals of Aboriginal and Torres Strait Islander background. Increasing Indigenous participation in healthcare service provision should be a priority, as it is likely to contribute to greater cultural sensitivity and a more welcoming environment for Indigenous patients.4,13 To achieve this goal, barriers to the retention of Indigenous medical and nursing students need to be identified and addressed to create a culturally safe learning environment.18
Training should also be provided to non-Indigenous health workers to enable them to deliver culturally appropriate care to Indigenous patients.9 Cultural safety training for practice staff was seen as critically important, however, divisions reported that due to training not being accredited by RACGP, many were still waiting to deliver their training programs. In addition to education and training, ongoing incentives are likely to be required to retain primary healthcare providers, particularly in rural and remote areas of Australia.3
The majority of divisions noted that collaboration with existing Indigenous services and the local Indigenous community were important to the success of the Closing the Gap Initiative. Divisions focused on developing trusting working relationships with existing services and sought active community involvement through formal and informal consultations with community representatives and elders. Thus, community views and expectations were incorporated into program design, ensuring that the unique health needs of local communities were addressed. Such strategies have been highlighted as being critically important in the literature, with partnerships between organisations, collaboration across different sectors and the active involvement of Indigenous communities in project design ensuring that initiatives are undertaken with, not for, Indigenous Australians.13–17 Furthermore, it has been suggested that partnerships established with Aboriginal community controlled health services offer opportunities to pilot interventions, which can subsequently be implemented in mainstream primary care settings if successful.5
Practice staff discomfort asking patients about their Indigenous status was highlighted as inadequately addressed barrier due to the delayed cultural sensitivity training. It is essential to address this issue, as effective identification of Indigenous patients can enhance uptake of relevant Medicare items and improve referral pathways between services.10 Comprehensive and ongoing cultural safety training for staff is likely to contribute to improved cultural safety in primary healthcare settings and thus lead to improved access to services for Indigenous Australians.
It is important to acknowledge the limitations of this study. The data were drawn from division 12 month reports, which were of variable quality. Before approval of the 12 month reports, the government assesses their completeness, focusing on how well the objectives and identified needs are being met and whether activities align with program outcomes. Thus, while the reports were of variable quality, all covered the essential components that were the subject of this study and the general nature of the activities could be established for all divisions of general practice.
Another potential weakness of this study was that divisions may have provided biased reports and no triangulation of data was possible. Divisions were reporting to their funding body. Divisions did generally present their Closing the Gap activities in a positive light, and ongoing challenges and difficulties were frequently attributed to the actions or attitudes of others, such as practice staff and members of the local communities. However, the aim of the reporting process was to provide individual feedback to divisions so that they could improve and plan for future activities. Poor performance was not associated with direct negative repercussions hence there was no explicit motivation to provide inaccurate representations of Closing the Gap activities. Many divisions did identify a number of ongoing challenges and difficulties.
Summary
Overall, divisions of general practice appeared to have a positive attitude toward the Closing the Gap Initiative. All divisions undertook a range of activities over the reporting period and a number provided details about specific barriers that their local Indigenous population encountered when accessing mainstream primary care. Divisions highlighted the importance of developing working relationships with existing Indigenous health services and local Indigenous communities and described how these relationships have evolved over the reporting period.
Implications for general practice
- The Closing the Gap Initiative was generally well received among GPs and practice staff and contributed to greater awareness of Indigenous health issues.
- Collaboration with Indigenous health services and the local Indigenous community was reported to be critical to the success of divisional Closing the Gap activities.
- Bulk-billing should be promoted, as it was identified as a key issue affecting Indigenous Australians' access to primary healthcare.
- Some GPs and practice staff continue to be unaware of Indigenous health issues or disinterested in Closing the Gap activities.
- Greater effort is required to target these individuals through cultural safety education and training and evaluation through regular staff performance reviews.
Conflict of interest: none declared.