Background
Theoretical framework
“The metaphor of ‘holding’ (kanyininpa) is rooted in a powerful experience: it derives from a linguistic expression describing how a small child is held in one’s arm against the breast (kanyirnu yampungka). The image of security, protection and nourishment is immediate. Extension of this usage characterises a wide range of relationships as variants of this mixture of authority and succour. An older woman who oversees and looks after the younger girls and women in the single women’s camp is said to ‘hold” them.”[20]p.212
Methods
Setting/participants
Interview conduct
Analysis
Ethical considerations
Results
Service | Urban 1 | Urban 2 | Regional 1 | Regional 2 | Regional 3 | Remote 1 | Remote 2 |
---|---|---|---|---|---|---|---|
Service population (% regular clients) | 3444 (63%) | 2882 (76%) | 504 (63%) | 748 (76%) | 11740 (70%) | 780 (72%) | 1100 (91%) |
Indigenous governed | No | Yes | Yes | Yes | Yes | Yes | Yes |
Indigenous manager | Yes | Yes | Yes | Yes | Yes | Yes | No |
Workforce total (Indigenous)
| 26 (9) | 42 (23) | 6 (5) | 9 (4) | 133 (103) | 7(2) | 12 (6) |
General Practitioners (Indigenous) | 4 (1) | 6 | 1b
| 2 (1) | 8 | 1 | 1* |
Registered Nurses (Indigenous) | 9 (1) | 1 | 2 (1) | 1 | 14 (2) | 4 | 3 |
Aboriginal Health Workers | 2 | 3 | 0 | 2 | 17 | 2 | 2 |
Allied health staff | 3 | 0 | 0 | 0 | 2 | 0 | 0 |
Chronic disease specific staff | Yes | No | No | No | Yes | Yes | No |
Systems
| |||||||
Electronic record system | Practix | MDc
| Ferret/ MDc
| MDc
| MDc
| Communi-care | Communi-care |
Automated pathology | Yes | Yes | Yes | No | Yes | Yes | Yes |
Disease register system | Yes | Yes | Yes | No | Yes | Yes | Yes |
Home medicines review | No | No | No | Yes | No | No | No |
Transport services | No | Yes | Yes | No | Yes | Yes | Yes |
On-site specialist services
| |||||||
General physician | 2 weekly | 2 weekly | - | monthly | weekly | 2 monthly | yearly |
Cardiologist | - | - | - | - | - | 6 monthly | yearly |
Nephrologist | - | - | - | - | - | - | - |
Ophthalmologist | - | - | - | - | - | yearly | yearly |
Podiatry | - | weekly | - | - | - | 6 monthly | - |
Dietician | daily | - | - | monthly | daily | - | 3 monthly |
Dentist | daily | daily | - | - | daily | 2 monthly | 6 monthly |
Local hospital services
| |||||||
Cardiology | Yes | Yes | No | Yes | Yes | Yes | Yes |
Cardiac rehabilitation | Yes | Yes | No | Yes | Yes | No | No |
Nephrologist | Yes | Yes | No | No | Yes | No | Yes |
Dialysis | Yes | Yes | Yes | Yes | Yes | No | Yes |
Theme 1: AMSs are different from private general practice
I suppose, as an Indigenous doctor, you often get (patients saying) “I’m happy to talk to you about this, but I wouldn’t really want to talk to the GP down the road about it… If it’s something to do with emotional, cultural, spiritual stuff, then that really does need to be addressed. But, you know, mainstream practices might not see it as ‘true’ medicine. (GP1, regional AMS2)
Even though we're a mainstream health service we do work really strongly with the community. There’s nothing more important than having local people (on staff)… that liaise between the community and us… We still have that strong contact, especially with the elders… Normally mainstream health services never venture out in Indigenous health to actually work with the community and not many (patients) come to them. (Clinical director, urban AMS1)
Daniel (pseudonym), an Aboriginal project officer, works on a shared responsibility agreement with the football club.… I think that is a really good example of delivering health in a very different way and engaging the community’s strengths. Rugby league is a huge factor for a man and it shows in figures that men attending the clinic are still under represented… So this work has seen an investment of infrastructure in the community sector as well as furthering this clinic. (AHW project officer 1, urban AMS1).
Being a community controlled service you not only have it (community control) at the board level but it should be reflected in the organisational structure right through to even the groundsmen…it gives the staff themselves a sense of belonging and knowing that it is owned by the community. We all live in this community so we're a part of the organisation and we’re working for it, showing to the wider community that we are able to work at all these different levels.(AHW1, regional AMS3)
Theme 2: AMSs under threat
The Board are better equipped and better able to run the health service because they're from the community, they know what the community need. To me it's a best practice approach, it's an evidence based approach because we are the community. We know what we want. We don't always have to be told “you need this, you need that”, or “ you should be doing this”… (AHW1, regional AMS3)
There’s probably to some extent a fundamental flaw in that we aren’t as community controlled as we’d like to be. We’re controlled by a different community, which just doesn’t make sense. (The local Board is) a bit of a toothless tiger unfortunately… (GP1, regional AMS2)
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.(Board Member, AHW1, Urban AMS2)
Theme 3: A pressured workforce
Lack of staff
In the past, patients would have a preventive health check but this has stopped because there's been an influx in acute care….That leaves the doctors no time to manage chronic needs and help patients to self-manage… So I think we need to look at how are we as an organisation going to tackle acute care… This would then have an impact on chronic disease because a lot of the acute problems are manifesting as chronic disease later… (GP1, regional AMS3)
Aboriginal Health Workers roles and support
Doctors tend to talk big words and a lot of community people don’t understand that. So I'll break it down into our jargon and I put it straight to them… (AHW2, urban AMS2)
Where I feel most comfortable is around community-based health promotion and delivering health from an Indigenous perspective of health. So not just thinking about food and exercising but thinking about community well-being. (AHW project officer 1, urban AMS1)
There’s a lot of issues because for both of our health workers there’s family groups that they won’t go near… I just think that being a health worker here is a position that doesn’t have any credence or respect in the community… Ideally the health worker here would be someone who’s Indigenous and knowledgeable with the people, but who’s not from here, who is impartial to all the different groups of people here. (RN1, remote AMS1)
Workplace orientation and professional development support
“It’s very refreshing and very exciting having one of the other doctors who is Indigenous… Everybody wanted him because he’s confident, affable and smart… Although it was fantastic having him in that role, it was also very difficult for him to actually perform it because he had so many other responsibilities” (GP1, Regional AMS3)
Theme 4: Drivers for quality care
Organisational influence and leadership
To provide good chronic disease management you need great systems and at the moment we've had problems with that…. From experience, systems are always forced upon us by higher management… systems we don't want. (Clinical director, urban AMS1)
Delivery systems and care planning
You can spend all your time chasing Medicare dollars… you can do health assessments just for the sake of doing health assessments and not actually help the patients…. It’s not necessarily the great pot of gold…it’s not going to solve all your problems… And chasing a handful of dollars, sometimes you don’t pursue the right directions, and your directions should be primarily improving the health of the community that you’re working with. (CEO, regional AMS1)
Information Computer Technology/ Information Management (ICT/IM)
I would love to marry Ferret, Communicare and Medical Director all into one… They all have something that's so good and then there's a part of them that’s so crap… We all need different bits out of it. so the doctors need the clinical side, health workers need the management side and the Board and management need data for their reports, for funding purposes. But one program never gives all of it… I think the person who comes up with this program is going to be a national icon! (AHW2, regional AMS3)
Theme 5: Candidacy to hospital and specialised care
We had a young Aboriginal fella, he went to the hospital and the nurse asked him “when was the last time you had a bath?” … (The person then walked out). And I heard about this young fella over the weekend and Monday morning, we went looking for him. We brought him in to see the doctor. It turned out he had an abscess on his lung which was really serious and he had to be hospitalised straight away…(AHW1, regional AMS1)
One of the issues is that people at the end of the line are so busy.that they don’t actually think, “gee this person comes from a 1000 km away, so we actually have to think differently”. Yes, we need to do what we would do for everybody else but hey, we can’t send them back and get them back next week (GP1, remote AMS1).