Sammi: Good evening everybody welcome to tonight’s twilight online 5 Steps to Delivering the Best Care for Aboriginal Patients webinar. I am your host for this evening. Before we make a start I would just like to make a quick acknowledgement of country. We recognise the traditional custodians of the land and see on which we live and work. Okay. I would like to welcome our presenters for this evening, Dr Tim Senior and Dr Cris Carriage. So, Tim is a GP at Tharawal Aboriginal Corporation in South Western Sydney. He is an RACGP medical advisor for the National Faculty of Aboriginal and Torres Strait Islander Health, a senior lecturer in general practice and indigenous health at UWS and an RACGP medical educator. Cris is the indigenous program officer at School of Medicine at Western Sydney University. So thank you Cris and Tim for joining us tonight.
Tim: Good evening everyone, nice to be here.
Cris: Hello everyone, how are you?
Sammi: In saying that, I will hand over to Cris and Tim now to take us through the learning outcomes for tonight.
Tim: So good evening everyone, it is lovely to join you here. Cris and I are joining you from Tharawal country in South West Sydney and we are both joining you from Picton. These are learning outcomes which is essentially educational speak for this is what we want you to have learnt by the end of the session, so at the end of this session of this hour together, we hope that you will be able to explain how to systematically identify Aboriginal and Torres Strait Islander people in your practice, to discuss key health issues confronting Aboriginal and Torres Strait Islander people, to explain how to use the Medicare health assessment Item 715 and the related follow-up items crucially to address the health issues identified and will be able to list where to access appropriate clinical guidelines to deliver high quality care. I am just getting a few notes there that there are a few people who cannot hear me, I hope there is not an issue with my microphone. So if we move onto the next slide.
One of the things we are going to do tonight is take you through, the college have a new set of guidelines which is hopefully making it simple for practices across the county and across the state to do Aboriginal and Torres Strait Islander health well and we have essentially developed five steps and we will take you through these five steps and the other important thing is that one of the steps will be introducing you to a resource that is about to come out very soon, the third edition of the National Guide to Torres Strait Island Health Assessment in Aboriginal and Torres Strait Islander people. So, if we look at the five steps first of all, we will take you through these and will give you a commentary on each one of them. Feel free to post questions in the question box as we go through.
You are going to see this slide fairly frequently through the presentation, the reason for this is that one of the crucial things about doing Aboriginal and Torres Strait Islander health well, is the circumstances in which people live and this is general practice really, understanding people in their context and all the problems that we might identify and the strengths that people have and the advice that we give, is dependent on what we see in the context of people living. If you are an academic you would call this social and cultural determinant of health. I often think that if you are able to use those terms then you are not subject to poor social and cultural determinant of health. But the context of people living in terms of employment and income and their ability to get healthy food and their experience of racism in various parts of society that they come across, their early childhood development and education, their housing and their interactions with Centrelink, Medicare, police and legal systems, experience in the criminal justice system and the choices that people make that affect their health, those are all determined by their context. As GPs that will not be news to you but it is really important in doing good aboriginal and Torres Strait Islander health that we understand those and we take those into account as we are doing them. So, we will be coming back to that slide every so often just to reinforce that doing aboriginal and Torres Strait Island health well, is not just about a set of medical conditions, though it does include treating those medical conditions well. Cris, anything you would add to that?
Cris: There isn’t any cultural context in that.
Tim: No and that’s right, there. So, while those dot points don’t include many cultural determinants, people’s ability to live out their own culture is a crucial determinant of health. Those of you who are working in cross-cultural areas routinely will come across that a lot. It can be a difficult thing to describe without actually experiencing it. That will become more apparent as we go through.
Cris: I think it is just our way that we can describe how people interact with their community which we know is really great for emotional wellbeing and that mental health part of people’s contacts and things like that. So, I think it is just a bit more than cultural practice, it is a way to interact with people’s community.
Tim: Okay, if we go onto the next slide.
So, this is the first step in the five steps, this is a summary of the five steps. We will be sending around a link as to where you can get the resources around these five steps as well as we go through. Essentially, what we will be going through is that the first step is to prepare your practice and register for the Indigenous Health Practice Incentive payments. Even with the changes to the Pitt Program that are suggested, it looks like the Indigenous Health Practice Incentive payment will be remaining.
The second step is to actually identify which of your patients are Aboriginal and Torres Strait Islander patients and sometimes that is not obvious but we will be saying exactly why that is important as we go through.
The third step is to offer or to conduct health assessments on your Aboriginal and Torres Strait Islander people, to identify the relevant health issues for those individuals and to work out tailored plans for those, we will be talking about the crucial components of that and some of the resources that go to the best evidence on the best way of doing that.
The fourth step is really important, it is one of the ones that patients appreciate the most. That is registering patients with chronic disease or patients at risk of a chronic disease for the Closing the Gap PBS co-payments.
The fifth step is actually tailoring care. There are some useful specific guidelines that could be used in Aboriginal and Torres Strait Islander health that are very important.
So, the first step is to prepare the practice. Really this is just recognising that in doing Aboriginal and Torres Strait Islander health well, it is not just the individual responsibility of the GPs but actually doing it well depends on the whole practice. The Indigenous Health Practice Incentive payment has been going for a few years now and registering the practice for this payment and then registering individual patients generates some income to be able to provide chronic disease management for your Aboriginal and Torres Strait Islander patients well. Ensure that at least one of the GPs and one other staff member from the Department of Health have undertaken cultural awareness training and create a welcoming environment. Cris have you anything that you would suggest about the importance of cultural awareness training and the environment for general practices that make it welcoming for people.
Cris: Yeah, I just think that sometimes we tend to think that we are symbols of aboriginality on the walls or whatever can be just that that is enough but I think we need to take it that step further and it is about that relationship, being Aboriginal or not, if you don’t have that relationship I think that you can lose patients in that way. It is about the relationship and I know that Aboriginal people like connections with where they are actually being seen for health and stuff like that. So, it would connect well wouldn’t it?
Tim: One of my favourite pieces of research was done in Mt Isa where they asked Aboriginal people and non-indigenous people what were the barriers to appropriate health care. Non-indigenous people tended to talk about policies and procedures in the practice, the posters on the wall, the pamphlets that were available and that sort of thing which would be very familiar to people. Aboriginal people said; actually none of that matters, what we need is having a relationship with individual people in the practice. And as GPs we should all understand that well and be able to provide that given that the therapeutic relationship with our patients is more to what we do. That is what Aboriginal patients are desperately crying out for and if we do that well you will have patients who are really happy with the service you provide, even if the posters on your wall are no good at all. Sometimes that is what gets people peering in through the door, so a poster or an acknowledgement of country on the reception just says to Aboriginal and Torres Strait Islander patients, we have thought about this, we are aware of peoples experience. Certainly asking Aboriginal and Torres Strait Islander patients their experience in other health services can be a real eye opener because too often that has not been good and so if we can be the one practice that provides a different good experience then that is really useful. Cris, any advice you give about cultural awareness and training for that or what are the crucial components of that?
Cris: Awareness is one thing that creates that sort of knowledge which we all know what part of that it is, I think that, I guess it is that stuff that you take a step further and how do you apply your cultural awareness to your practice is what Tim is talking about. I think that in creating those relationships and stuff and understanding where people come from because of what you have learnt, I think that creates that trust which we are all trying to do with all our people that we work with. So, I would be more interested in the fact of how do you apply that awareness to when we are seeing an Aboriginal and Torres Strait Islander patient and I think that is something that we all sort of like have to deal with. How do you do it?
Tim: It is often easier said than done and I think one of the focuses for this hour will actually be about understanding the context, the thinking and the culture of the patient sat in front of you. Often they will be able to guide you around that with questions like “What are the sorts of things that you think will help with this, what are the sorts of ideas that you have about the cause of this, what would you like to do about this?” Really inviting people to be involved and in control of their care. Look, we will come back to that issue frequently because I think it is an important one.
We can move onto the next slide.
So, this is just about the Indigenous Health Practice Incentive Payment, so when the practice signs on you get a one-off payment of $1000 for your practice. For each patient that you register you get $250 per eligible patient each calendar year, so you register people each year for the Aboriginal and Torres Strait Islander payment and then when you provide the majority of Medicare funded care for a patient you get extra payments. So if you provide the majority of care for a registered patient in a calendar year then you get $150 for each patient in a year and when you provide a GP Management Plan and a review of a GP Management Plan or two reviews you get $100 for that patient. Now the statistics that I am aware of on the Practice Incentive Payment is that for quite a lot of patient registrations being done but actually very few patient outcome payments are being made, which I think says that we are very good at registering people but we are not as good at following people up as a result of that. There is the same evidence of Aboriginal health assessments.
A question, how do we register for this? So you register in the same way that you register the practice for other practice incentive payments, because it is Medicare it is quite bureaucratic, for each patient you have to register them on a particular form, the GP signs the form, the patient signs the form and an eligible authorised person at the practice signs the form and then faxes the individual form off to Medicare. Then that patient is registered. It is the same form for registering the patients for the Closing the Gap PBS co-payment thought the criteria for that is slightly different, it gets a bit messy. There is reasonably good guidance on the Department of Health Medicare website and often PHNs are able to help you with that locally as well. Practice Managers are often more across that than GPs are. Obviously only accredited practices are able to register for this.
We can move onto the next slide.
Step two is really important and that is to identify your Aboriginal and Torres Strait Islander patients. We know that generally health services are not that good at doing this. I think GPs are getting better at this. There are two important steps; one is asking the right question which is do you identify as Aboriginal and Torres Strait Islander and then you record that in the notes as Aboriginal, Torres Strait Islander, both or neither. Now a lot of people worry that they will offend their patients by asking both indigenous and non-indigenous patients, but actually if you explain why you are doing it then people are usually very happy about answering that question. Not only should you be able to do that, but it is important that your reception staff are able to do that because they are the ones who are mostly going to be doing this. Cris, what is your feeling if you were at a practice and you were asked if you were Aboriginal and Torres Strait Islander what is your instant response to that?
Cris: Um, I usually go yes and then I know what that is about and so it is your average Aboriginal person who comes in and the first question is “why do you need to know that?” and I think that is having the reason why and in people’s own words, who comes across genuine, will actually put a lot of Aboriginal people at ease as well and I think that is the hardest part is actually putting people at ease, why are you asking this question, does it mean you know whatever; and so I think yeah asking people is hard when you first do it but usually people have a story, you know, they have it in their own words and I think that makes it much easier for people to actually go, oh yeah. It is also part of developing that relationship too and making it not sound like it is going to be an awkward sort of question or awkward situation when they are asked.
Tim: And it is worth remembering that for some patients that question would have been asked around removing children, so there are grandparents around where it is really an awkward question to be asked, and so being able to reassure people that actually it is to provide the best clinical care, some of the immunisations are different, some of the recommendations on preventive health care are different and it allows us to tailor their care most appropriately for the patient and to understand some of the things that may have been in their background and experience with some issues that have come up with them. But it actually affects clinical care which is why it is so important.
A question has come through here and is one of the common questions about this. What if the patient cheats? It is actually really unusual. I know of one or two GPs that have been audited for recruiting thousands of non-indigenous patients to close the gap. The census numbers are known so if you are a service where there is 100 people in your area who identify as Aboriginal and Torres Strait Islander and then you register 2000 it is clearly wrong. In general Aboriginal and Torres Strait Islander people have historically been kept out of services and kept away from services and the funding has been less, so if we think about it as we can choose to be sensitive or specific; if we choose to be sensitive we give the service to all of those who might be eligible but we may give it to one or two who are not eligible as well, or we could choose to be specific where we are really tightly targeting it so we know that only those getting it are eligible but would also miss many eligible people because we are being too restrictive. That is historically what we have done, we won’t actually improve people’s health if we are being too restrictive on applying it. There is actually very little evidence that there is much rorting in this at all. If people explain then they are very happy. People are usually honest, there is not much evidence of rorting. However, the important thing is, you are not required as non-indigenous GPs to police this. It would be a great way of ruining the doctor-patient relationship if the first thing you are doing is questioning someone’s aboriginality. So if someone tells you they are Aboriginal then you can believe them. Unless there is evidence of you rorting the system and I suggest you don’t do that, Medicare will accept in good faith what people are telling them. The link on that page by the way goes to this document which is the college position paper on identification of Aboriginal and Torres Strait Islander people in general practice. There has been quite a lot of good research about this and that summarises some of that and gives recommendations for use in general practice. So do have a look through that and encourage your practice team to look through that as well.
Going back to this slide again, again just to remind us that the history of being asked that question is not blank and being aware of that means you are more likely to ask in a sensitive way, that there is a history of Aboriginal and Torres Strait Islander people being asked that question in order to be discriminated against. So, I remember you saying something about the dog tag to me Cris, about reaction, about historically what that meant? Do you want to say something about that?
Cris: So, that is when Aboriginal people used to have a piece of paper that said they were exempt from being Aboriginal. My grandmother had one and she could go into shops to buy food for the kids and she used it to her advantage to actually better the family but the counterpart of that was also they were ostracized from their community or they were still not even accepted into the wider community anyway. So it was used to actually let them use services, go into the supermarket, all that sort of stuff. We had our own little mini apartheid.
Tim: These are vivid memories. People still draw on those memories when they are wondering why we are asking these sort of questions. So, again, social and cultural determinants are important.
As we move onto the next slide I am just looking at some of the questions coming through. There are some specific questions about particular scenarios in people’s individual areas. If you have a look at the map of Aboriginal and Torres Strait Islander Australia, you will see it is vastly different, there are hundreds of different countries across Australia and so for some of those specific questions we actually won’t be able to give you a specific answer here because a lot of that is about local knowledge in your area as to whether there are particular services and so contacting organisations locally like perhaps a local Aboriginal medical service the PHN might know as a local and even local councils and local Aboriginal land councils will often be able to help with those questions about services in your area.
So, the next step is about conducting Aboriginal and Torres Strait Islander health assessment which is the MBS item 715. You may well have heard about this already. The 715 is different to other health assessments that you might know of, it is not based around time, you get to bill that item number no matter how long it lasts and you get to bill that item number for the three distinct ages; so there is a children’s health check, an adult health check and there is an older persons health check but it is the same item number for all of those. It is designed to find particular problems and conditions that people are experiencing and gives an opportunity to discuss solutions to those problems. I think crucially it is also an opportunity to build rapport with people. As we were saying, that relationship is so important and so it is not just a medical questionnaire but it is about building rapport and essentially being able to say to people, look your experience in other health services may not have been great, we are going to give you a fabulous experience. So that people leave the health assessment really wanting to come back and see you.
Cris: I also think that follow through is something really important. I think that we need to make sure that if there is an issue or something like that, it is actually following through with that and just making sure that the patient does come back for that, I think it doesn’t happen so well.
Tim: And the statistics only back that up. The number of health assessments being performed is on the rise but the number of follow ups from health assessments is not that high. If they are going to make any difference at all, the follow up of health assessments is absolutely crucial. We will talk about that in a little bit as well.
We have a comment coming through as well, that sometimes patients deny being Aboriginal and so again that history is one of the important reasons that people may do that.
Going to the next slide. It says a bit more about the components of a health assessment. So, I think it is worth noting that health assessments are fairly widely known in an Aboriginal and Torres Strait Islander community so people will often say “I am here for a health check, I am here for my health assessment” and so I think the awareness of them is quite high now and people accept them as a way of getting health care.
Medicare require you to collect information, including taking a history and doing examinations and investigations as required, to make an overall assessment of the patient and recommending appropriate interventions and provide advice and information. Obviously keep a record of the health assessment and offer them a written report. It is a carer offering them a copy of the report. It can be done, while the GP has to summarise the information and have a discussion with the patient, a lot of the information can be done by an Aboriginal health worker or a practice nurse and you can see the Medicare requirements in general, though in general leave the clinical decision making up to you but it is about taking a thorough history and examination and making recommendations based on that. Anything you would suggest?
Cris: I just had a thought. I think too, around the health assessment is to get Aboriginal and Torres Strait Islander people to think differently about their health. I think it just a bit more than, you know, like sometimes they come in with an attitude and yeah it is going to happen anyway, but I think we need to start thinking about regular checks and with regular help we can actually improve your diabetes, we can actually improve your weight, we can organise those things that most other people have that sort of view when they come into the clinic and I think that is the stuff that is the toughest thing to change our view on our own health status.
Tim: I think that is a really good point. I have met quite a few people where their brothers or sisters have died say in their mid to late 50s and they reach that age and they have a sense of inevitability that that is going to happen to them. One of the important things we can do is say, “this isn’t inevitable, there is a lot that we can actually prevent if we do well”.
There is a question coming in asking about whether family members have mental illnesses or not is culturally sensitive? There is a widely understood concept now with Aboriginal and Torres Strait Islander communities of social and emotional wellbeing. There is actually a broader concept of our concept of mental health, that being healthy and well is more than just an absence of diagnoses such as depression or schizophrenia but it is about your wellbeing in the context of your community and family. When asked in that way, I have never come across a patient who says “Oh I don’t feel comfortable with you asking me about that”. Would you feel that people would be comfortable being asked about that.
Cris: I think the hardest thing about this is just finding mental health for an Aboriginal community or family, because I think that if you said that someone was sad in my family, I could tell you yes. If you say they have depression, I wouldn’t know in the sense. So, there are these sort of levels of what mental illness is and so that is probably the hardest part about that and I think if you say, I don’t know how you would even answer, saying mental health is one thing but saying emotional wellbeing or you know, yourself, I think is harder.
Tim: Most patients have family members or friends who have been affected by mental health issues and so they understand that and they see the effect on people and they don’t want it to happen to them. It is difficult for everyone to talk about their own mental health.
Cris: You say mental health has a stigma straight away and that is the thing I think they avoid the most. When you say, are you sad or you are not coping or anything like that, then we can go okay what is it, I am frightened to go outside, then that is an anxiety sort of issue as well. I think it takes another family member to bring someone to the service that says there is something wrong her and we need to actually help.
Tim: Yeah, that is a really good point. By actually not talking about it in terms of a particular mental health diagnosis but talking about it in terms of what you do and how you feel in the community and what it stops you from doing, like feeling frightened about going out is much more important than saying, do you have an anxiety disorder?
What works to engage people to come in for their 715 health checks? Different clinics have done all sorts of different things, AMS Western Sydney have published about their health days and the services that do big day of offering checks and the services that we offer fruit and vegie boxes to some of our patients through a subsidised fruit and vegetable program, other services will offer T-shirts to people to come, there are various things like that. In general, it comes from the community themselves.
Cris: Yeah, it is changing the narrative of what health is I think for Aboriginal people and changing their view of their health and I think that is the hardest thing.
Tim: Yeah. If we go onto the next slide which I think will be familiar to you because it is important again to realise that a lot of the health issues have this social and cultural background. Cultural being a strength, connection to culture is a protective strength and is important to determine and so much of those issues are very important in the experience of people’s health.
Cris: It is interaction with family, community, it is a whole range of issues that is part of that cultural makeup of what makes the community and having those places to go or somewhere where they can interact with their family and community on the whole.
Tim: Someone is asking, do you do a mental health assessment in their next appointment? Do it when you feel it is appropriate. Depending on the relationship, there is no hard and fast rule about that.
Someone is asking, do you do an Aboriginal health assessment instead of a GP management plan? So people with a chronic disease is still eligible for a GP management plan, so you can do both if people have a chronic disease and I would suggest that would be a useful way of utilising Medicare for your care.
How often do you do a 715 assessment? They are designed to be annual but actually you can bill another one after nine months but it is designed to be an annual health assessment.
So if we move onto the next slide.
This is about follow up. As we were saying, follow up is really crucial. It hasn’t happened, statistics show that it has not been happening as much, but you can actually your practice nurses can bill 10987, remember that, to provide follow up activities arising from the health assessment. So talking to patients about taking medication and monitoring for that, checks on clinical progress and accessing other services, education and monitoring council activities, lifestyle advice, going through the medical history and prevention advice with associated follow up. So that is another, that can be a really useful option for use in your practice.
Oh, before we go onto step four, the other thing about follow up is that it is a whole of practice activity, so don’t just depend on your memory or the patient’s memory for the follow up activities, use your practice system, so use your recall system, discuss with the practice manager and receptionists about how you can get people back, use your appointments book proactively so that if you see someone who has had a health assessment coming back in then you are able to do some of the follow up at that point as well. So have an active follow up system.
Step four is registering patients who have or are at risk of a chronic disease for their Closing the Gap PBS co-payment. One of the biggest barriers to people actually taking their medication was being able to afford the medication and this has been one of the most successful measures in the whole Closing the Gap program that is was actually reducing the cost of medication for Aboriginal and Torres Strait Islander people. So, registering them for the CTG means that all PBS medications, not just the ones for chronic disease or preventing chronic disease, everything on the PBS is reduced in cost. So, for people who are not on a health care card or pension, that reduces cost from about $36 to $6 (to the pension cost) and for those who are on a health care card or pension it reduces the cost of each prescription from about $6 to being free. That has made a huge difference to people, actually being able to make the decision to take their medication and be able to feed the family rather than chose one or the other. Anything you would say about that Cris?
Cris: I think it has made a big difference in people’s lives who are on the edge too and that is sort of like no making them suffer and I think it makes a big difference to people’s lives, I really do.
Tim: Yes. When you look at the statistics about people’s income and see why this is such a big thing, because the troubles that people have with income makes it really difficult to be able to just afford basics that we all take for granted.
If we move onto the next slide.
So, again just remembering, this is to remind us that income is really important.
There is a question coming through about any strong criteria to register Aboriginal and Torres Strait Islander. Some people say their parents are Aboriginal but they are not sure. In terms of general practice, the only criteria is if someone says they are Aboriginal and Torres Strait Islander then they are Aboriginal and Torres Strait Islander and you don’t need to get into an argument about that. It only provokes grief. So, if someone choses to identify then for our purposes as a GP that is good enough.
Oh yeah, this is important. Can you get five sessions with allied health practitioners via the 715 and five sessions with the GP management plan? Yes you can. So for an Aboriginal patient with a chronic disease you can use the Medical Health Assessment 715 and the GP management plan and team care arrangement 721 723 to get 10 allied health appointments each year. You can imagine someone with diabetes who might need to see a dietitian, podiatrist, diabetes educator, those 10 sessions are really crucial and so we certainly do that at Tharawal and you are certainly able to do that.
Step five is about using appropriate clinical guidelines and programs from RACGP, Medicare, primary health networks and the local health district to enhance aspects and quality of care for people. And so, with the college I work in the RACGP Aboriginal and Torres Strait Islander health and so one of the big projects we have been involved in for a long time and is just coming out in the third edition is the National Guide to Preventative Health Assessment for Aboriginal and Torres Strait Islander people which is a partnership between NACHO which is the National Aboriginal Community Controlled Health Organisation and the RACGP and so if you watch out within the next month or so those guidelines are going to be launched and those are essentially like the red book for Aboriginal and Torres Strait Islander people. If you move onto the next slide I think we have more on that. So this is the cove r of the previous edition, the new edition is coming and essentially it makes recommendations based on the evidence for different preventive interventions and some of those interventions are slightly different to what you may be familiar with in the red book, predominantly some of the immunisations are different, some of the interventions start at a younger age than they do for non-indigenous populations; so for example testing cholesterol, checking renal function, testing for diabetes and there are also sections in the national guide for things like there is a new chapter on violence and abuse and picking that up. So, do what out, the second edition is still available on the college website but within the next month the brand new third edition will be launched, so do watch out for that.
Move onto the next slide.
Oh there look, that is a sneak preview of the cover of the third edition so you know what it looks like on the website and if you get hold of a hard copy which will be sent around as well.
Just some of the other questions coming through. The difference in Medicare rebate from a referral from a 715 and 721723? I cannot remember off the top of my head. They are very similar the list of allied health practitioners is just the same, I have a feeling the Medicare rebate is the same. The form is ever so slightly different, it has a different tick box at the list, it says 715 to tick rather than a 721723, it is pretty similar.
The other one is, do you have to do a 715 every year to get the five extra allied health sessions? Yes you do. So once you have used the five in a calendar year that is your lot and you have to repeat the 715 the year later to get the next five.
Are there any scheme for Aboriginal patients to access dental care under the Medicare rebate? No. This is a real gap. There is just a new, this is not just for Aboriginal patients but there is $1000 over two years Medicare rebate for children of families on the Family Tax Benefit Part A. $1000 isn’t much but that is what Medicare are offering for some child dental date. Dental services are really difficult to get hold of, public dental care waiting lists are long. Many Aboriginal medical services do run a dental service as well. You are right, dental care is crucial. Good teeth have an impact on everything, from being able to eat the fresh fruit and vegetables that we recommend to actually being confident enough to smile in your job interview to get a job. So it is actually really crucial.
This next slide is about the barriers to follow up, just being aware of the time. Have a think in your own practice about the reasons that people may not be able to come back for a follow up after health assessments. I think there is no right or wrong answers particularly in this, as each one of our practices are different and working in our own local context but it is important that we understand these in our area because coming to solve problems using the strengths that we have found in the health assessments is crucial to actually making a difference. So as suggested, the remoteness and isolation as in the photograph there, can certainly be a warning issue and that would be true in many parts of NSW and certainly in other parts of Australia. By no means all and it is worth remembering that the majority of Aboriginal and Torres Strait Islander people do live in urban areas so remoteness is not always a problem. Having said that, there are still barriers in accessing care, even five minutes away. Cris and I work, what Cris is on the board and I work in a service five minutes from the local hospital but there are still barriers for going to that hospital even though it is within reach.
If we move onto the next slide.
There are some good questions there. Yes, someone is asking why I said that. There are a few different reasons. One is that when people attend health services including our own, they are often treated rudely at the reception desk and income and affordability of services can be an issue for many people. The other calls on their time, so often people who are most in need of having health assessment follow up are also having to deal with Centrelink appointments, housing appointments, schooling, other medical appointments, work in their day to day and so there are lots of other calls on people’s time as to why they may not be able to make it.
I have found it useful and I think this comes from one of the research articles about the different levels of care that can prevent people from coming into services.
Someone put there, isn’t the hospital free for everyone? Yes but there is a two-year waiting list to get in to see a public ophthalmologist where we are and then another two years to actually get your cataracts operated on. There is no public orthopaedic outpatients clinic, it is a long waiting list for haematology, there is no public ENT appointments, so the public system; while it should be free often relies on the private system to get people in and the Emergency Department becomes the default physician where people are waiting a long time.
If we move onto the next slide.
So this is talking about the patient level, transport is a big issue and again sort of creating the desire in the community for people to follow up their health assessments and the systems in the practices to do that. Cris would you have any advice for people around sort of engaging community to enable people to come back for health assessments?
Cris: It’s okay. While I am thinking about it, there is a whole range of things and I think it is that thing we said before about relationships and building that trust and I guess it is a thing with the little personal touches, I think if you look at AMS’ and how they get people back, it is that shared knowledge, it is that someone asking how your aunt is going or there are extra questions that build your relationships. If you are in a practice where you have a relationship with your patients then I think remembering the smallest things sometimes can actually help. Yeah, I guess you have to think that sometimes people come in and have to navigate the surroundings, the staff, the other patients within that service and then understand the talk that doctors talk, about their own health that you can understand. I think sometimes it is just easier as Aboriginal and Torres Strait Islander.
Tim: And I do think that the relationship that you have with people, if that is there people are much more likely to come back. Do think about the practice systems that allow that to help.
Someone is commenting that in rural communities often there are transport buses with local drivers that are often very helpful. That is absolutely right. We work with drivers who take people around and recently have had several occasions where the drivers have made a significant intervention in knowing the patient well and realising that they are not well and have brought them in to see the doctors when the patient wasn’t considering it, so the drivers are really valuable both in the transport role and elsewhere.
Now it is just stressing the importance of cultural awareness. Really that can boil down to an awareness of the context that people are living in and what is important to them. So we tend to think that diabetes in important, ischaemic heart disease, HbA1c, blood pressure and patients feel that their grandchildren and connection to community and community events and looking after family is important. There is common ground in there but we need to understand that from the patient’s perspective.
Move onto the next slide.
Someone has given a really important comment about the involvement of the Aboriginal health worker. Many of you may not have an Aboriginal health worker in your practice but PHNs often include Aboriginal health workers and they can be involved and would be only too happy to be involved in your care. Hospitals often have excellent Aboriginal liaison officers who can really make the difference in transitioning the care between hospital and primary care. So do look out for those people and engage their help.
This is a health service level about follow up, so that using the clinical information system, using all the staff and again ensuring that all the staff in the service are able to develop a relationship with your patients. Again cost is an issue there, about communicating cost implications in follow up and finding ways around that often so that there are often schemes locally with integrated team care program which is usually contracted out by the PHN to a service in your area. Look out for them because they are often able to help some of the cost barriers. Specialist care can be difficult. There are programs run by the NSW Rural Doctors Network for getting specialist outreach programs into different communities and I know the Royal Australian College of Physicians is also doing quite a lot of work to try and get specialists outreaching into communities across Australia including NSW. So, this is community level and Cris you are often, I have heard you say before, community know what it is that they need and they don’t need to be told again that they are sick. So what would you say about how communities, what they know and what works for getting communities engaged in doing health assessments.
Cris: Ah, like in health workers or as in …
Tim: So what practices can do to make this work better for actually doing follow up of health assessments.
Cris: I really like your suggestion about getting the PHNs team involved with the care and stuff like that, I think sometimes it can be quite difficult for that connection and sometimes the Aboriginal health worker has that connection with the patient themselves. I think that there is a whole lot more than just, a sort of like a community sort of, with the Aboriginal knowledge and I think it a thing around if you show that you care and building that trust and just say we are going to have someone else as part of your care, I think that the Aboriginal people would go, oh okay then so you know, and having the Aboriginal liaisons coming in with the Close the Gap Team and PHNs. It just makes a better whole of care than just having it all placed upon the one person, the doctor, and stuff like that. I know that you don’t use just you, you have a whole team that sits behind you that helps you with the patient and stuff like that.
Tim: And certainly, I am lucky enough to be able to work with Aboriginal health workers who regularly just are able to give me a heads up on what is happening with someone or what is happening in their family or some issues that they didn’t feel comfortable raising with me, that they are aware of or has been mentioned. It just opens my eyes to something that I wouldn’t have guessed that allows me to provide much better care. So, I think that can be a really important thing. They can say things to patients that I could never get away with say, they will grab someone by the ear (oh not literally) but drag them into my room saying get yourself in to see the doctor and they can say it in a forceful way that I would just alienate someone if I did that but because the health worker is in the community and trusted by people and known by them, they can get away with being a little bit more brutal than I can.
Cris: I was driving and told somebody if they didn’t get into the ambulance then I was going to treat him myself and he jumped into the ambulance.
Tim: I just wouldn’t get away with saying that.
Cris: I mean, when other things we talk about like the Close the Gap in terms of the PHNs and that, I mean that is what they are for too and I think they have a team of things to do but I think as GPs actually trying to utilise them better and formulate a way that they can actually help you with the care, health care services is a really good place to start with. They can also help you break down those barriers within your service and staff as well.
Tim: Yeah, absolutely.
I think the take home message from that is really that the health assessments can be a useful tool but only if the follow up is done and done well, and that sort of thing requires the use of practice systems rather than just memory and hoping that it will happen. I think again a reminder that the social and cultural determinants of health give people a large call on their time that may mean what is a priority for us takes a less of a priority if people are wanting to keep food on the table and a roof over their head. So it is very important for us to understand just the context that people are in which is very often very different to our own.
Someone has just asked me how many times a 10987 can be charged. That is a good question, I can’t remember just off the top of my head, I think it is five and we put in a submission to the MBS review arguing that it should be many more or uncapped because capping it can be a problem when it is limited but I think it is five.
There is a common question here that I think is important, about are there any taboo things that I should be aware of specifically when seeing Aboriginal and Torres Strait Islander patients, that may not be obvious to someone? Not really, Cris anything taboo?
Cris: No I don’t think there is, I think you just. I mean there is like women’s business and men’s business and I guess if you are a man working with a lady, especially an elder in the community, I think you need to ask those permissions. Do you mind if I touch you? Which you probably would normally do anyway, asking if they would like a female doctor or something like that and they usually will seek out a doctor that feel comfortable with too and so that is probably the biggest issue that you would probably come across. Male patients who, unless they are really elderly, will kind of feel comfortable with everyone, I don’t think they have such a thing and just being mindful of that sort of shyness I guess.
Tim: So, I have worked at Tharawal for 12 years now and I don’t do that many Pap tests and I don’t do much antenatal care, it’s not because I don’t want to it is just that is women’s business, but I don’t do none, so it is not an absolute hard and fast rule. I think the other thing is just some of the terminology, it is not good to call people ATSI, the acronym doesn’t work, don’t use some sort of derogatory terms which is obvious to say, you wouldn’t do that to anyone anyway but the correct terminology is Aboriginal as a collective noun and Aboriginal and Torres Strait Islander people, Aboriginal and Torres Strait Islander Australians.
Cris: So are you invited then to call people Aunty and Uncle, again if they invite you to?
Tim: Again I think about asking permission for that is important and in general, watch for the body language. If you are making people uncomfortable they will show it in the way that they are interacting with you. People have often been asked about whether eye contact is taboo, don’t worry about it. So in Central Australia when I worked there, people would avoid eye contact, it doesn’t happen at Tharawal in South West Sydney very often at all. Again, if you look at the Aboriginal map of Australia, then it is many countries and they all are slightly different and so it is going to depend on local sensitivities and there is not a single rule that would apply all across Australia.
If we move onto the next slide, we are just coming to an end now. This is the summary of the learning outcome. So, we hope, oh I am just having a quick look here. Oh, we have a question that was asked which I think is worth answering for clarity. Is it okay to ask are you Aboriginal? No, I am not Aboriginal and Cris is Aboriginal. I think one of the important things is; feel free to call out anyone offering Aboriginal health teaching who is not doing it as an Aboriginal person as that shouldn’t really happen. Aboriginal health for too long has been non-indigenous people talking amongst themselves about how to do it well and one of the most crucial things that I think would have come through tonight is to involve Aboriginal people in their own care. Develop that rapport and do that and that is going to be the most important thing.
I hope we have covered all those learning outcomes for you. You can let us know in the evaluation afterwards. I think Sammy is going to send round some links and possibly some resources and handouts. Those five steps we went through and the national guide are both available on the college website and there are three resources linked to the five steps. Feel free to have a look at those.
Sammi: Sorry Tim, I just want to also mention as well, that I have just posted a link in there. We are actually on the RACGP NSW and ACT faculty page we have a video there on identifying Aboriginal and Torres Strait Islander people in your practices, it is only a two minute video but it is a great resource. So please jump on there and have a look at that.
I think that brings us to the end of this evening. A big thank you to Tim and Cris for presenting it tonight and thank you to everybody who joined as well. We hope you found it really beneficial to your education as a GP.
Tim: Thank you very much everyone. Thank you Cris.
Cris: No thank you, thank you.
Tim: Have a good evening. Thank you very much.
Sammi: Just a reminder to everybody as well that this is a CPD activity. If you could please complete the evaluation so we can upload your points. Thanks.
Tim: Thank you Sammy.
Cris: Thanks Sammy.
Sammi: Good night everybody.