Marrabinya: Aboriginal Health in Aboriginal Hands

Culturally Safe and Coordinated Care for People with Chronic Disease

Rural and remote-living Indigenous people with chronic disease can face barriers of distance, cultural difference and cost in having often complex health care needs met in a coordinated way. Western NSW Primary Health Network (PHN) covers an area almost twice the size of the United Kingdom, where many diverse Indigenous communities live. Through Marrabinya brokerage, an Indigenous initiated, designed and controlled service, Indigenous people are identifying the barriers they face in accessing services and working with Marrabinya to address those barriers. It’s a model of care with potential application in other PHNs and service contexts.

Snapshot | Western NSW PHN and its Indigenous people

The Western NSW Primary Health Network is 1 of 31 PHNs across Australia. PHNs work with existing GPs, Aboriginal Community Controlled Health Services (ACCHSs) and others to support and strengthen high-quality integrated primary health care systems within their regions. This includes identifying service gaps and commissioning service providers to fill them. Western NSW PHN has identified that a selective rather than a public tender process generally delivers better results for Indigenous communities.

The Western NSW Primary Health Network covers half the area of NSW – over 433,000 km² – where there is a population of just over 309,000 with a significant Indigenous population. It has offices in Dubbo, Bathurst and Orange (all with about 40,000 people), Broken Hill (19,000) and Bourke. The PHN covers two Local Hospital Networks, while 405 GPs operate from 108 general practices.

Indigenous peoples with diverse languages and cultures have occupied the Western NSW PHN region for tens of thousands of years. Of the region’s current population, 10.5% are Indigenous. Broken Hill’s Maari Ma Health Aboriginal Corporation (Maari Ma) and Dubbo’s Bila Muuji Aboriginal Health Services Inc. (Bila Muuji) are two of the peak bodies for the ACCHSs that service the region. See Reaching out to Mums, Bubs and Children in Inner-city Melbourne.

Complete integration of Indigenous interests in the Western NSW PHN

ACCHS part of PHN consortium – the Western Health Alliance Limited (WHAL) operates the Western NSW PHN. The WHAL consortium includes Maari Ma and Bila Muuji, and the nine-member WHAL Board includes representatives from both. The PHN has formal partnerships with local Indigenous community bodies such as the Three Rivers Alliance and the Murdi Paaki Regional Assembly.

An Aboriginal Health Council advises the Board on Indigenous-specific health and related concerns, alongside two other Clinical Councils and two Community Councils that advise on mainstream and Aboriginal health concerns. Each council has a dedicated Board member who they liaise with to ensure effective communication from the council to the Board and vice versa. The integration of an Aboriginal Health Council within the PHN council structure is believed to be unique in Australia and is regarded as one of the drivers of the Western NSW PHN’s innovative responses to Indigenous health, including Marrabinya.

Case study | Western NSW PHN’s Indigenous chronic disease challenge

Reducing the impact of chronic disease in the Indigenous population is key to closing the Indigenous health gap. Cardiovascular disease, diabetes, chronic respiratory disease, chronic kidney disease and cancers are among the biggest potentially preventable cause of Indigenous deaths across Australia. Western NSW is little different – with Indigenous people presenting with complex and multiple chronic conditions.

Indigenous people with chronic disease requiring coordinated and effective care can face different challenges in different contexts. In Western NSW PHN, these include barriers of distance, cost and cultural difference. Primary health care services – where the bulk of care should be delivered – can be poorly linked to hospital-based and secondary services. Patients with multiple chronic conditions may require treatment and support from a range of services from different parts of the region and different parts of the health system. Poor coordination and communication among providers can ultimately affect the quality and safety of patient care, and these services may charge fees that are barriers for disadvantaged people.

Cultural safety practices help Indigenous people feel welcomed and safe in mainstream health service environments and thus help ensure services are accessible to them. In chronic disease care, where ongoing relationships of trust between staff and patients are critical to the success of treatment, this is especially important. Cultural safety in service delivery is enhanced by the presence of Indigenous GPs and, Indigenous Health Workers and staff. The Western NSW PHN perceives cultural safety/competence in the context of providing culturally safe practice, which includes being able to communicate effectively across cultural differences, and is also critical to working effectively with Indigenous people.

In 2016, the Western NSW PHN Aboriginal Health Council recommended that the PHN develop a Cultural Safety Framework to guide the region’s health and other relevant service providers, the PHN’s commissioning framework, and the PHN itself in building a culturally safe primary healthcare system in Western NSW. This framework was completed in 2017.

The Marrabinya chronic disease support brokerage

Integrated Team Care (ITC) is an Australian Government funded, Indigenous-specific chronic disease program administered by PHNs. ITC aims to improve the access of Indigenous people to culturally safe, coordinated care including by working with primary care services to increase their accessibility by Indigenous people. PHNs apply for ITC funding according to criteria that include strong PHN–regional Indigenous health service partnerships, as has been established in the Western NSW PHN through the WHAL consortium.

Marrabinya is the name chosen for the Western NSW PHN’s ITC program. Following a recommendation by its Aboriginal Health Council, the Western NSW PHN Board committed to commissioning its ITC program from among ACCHSs in its region using a Single/Most Capable Provider approach, rather than by open public tender. The successful proposal was initiated by Maari Ma and Bila Muuji as a distinct activity. They proposed a unique model of care involving working equally with GPs and ACCHSs, and staff being co-located in ACCHSs across the Western NSW PHN region. Through sharing facilities and office equipment, this would lead to significant overhead and wages cost reductions. Potential conflicts of interest were managed by the exclusion of Maari Ma and Bila Muuji representatives on the PHN Board from all decision making around the selection of the successful applicant.

The Marrabinya service model is unique. It is a single Indigenous-controlled brokerage service operating across the vast Western NSW PHN. But it has presence in many areas by staff being co-located in ACCHSs. Indigenous people with a diagnosed chronic condition and a current GP Management Plan (item 721 in the MBS) and/or Team Care Arrangements (item 723) must be referred to Marrabinya by their GP, including those based in ACCHSs. Marrabinya then has a Chronic Care Link Worker assigned to follow up with the patient and referring doctor.

Marrabinya supplements the work of ACCHSs and GPs by supporting their patients to first choose and then access and attend assessment, care and other services. Marrabinya’s role includes making specialist appointments; payment of specialist gap fees; paying for diagnostic tests where a fee applies; helping with applications to State Government health assistance programs; arranging and paying for transport and/or accommodation to attend health appointments; and purchasing medical aids. Walking frames and other aids and appliances can also be hired or supplied. All Marrabinya support is guided by GP care plans and what support is provided is communicated back to the referring GP.

Proactively promoting Marrabinya was critical to establishing its presence in the Western NSW health care system. Marrabinya commenced with about 600 patients. Within four months, by March 2017, client numbers had doubled – also suggesting the great need the service was meeting. It will take time to assess health outcomes from Marrabinya, but the Deeble Institute has conducted a preliminary service model evaluation and found it has potential to make a positive difference to the health of its Indigenous client group. Promoting cultural safety to providers throughout the region covered by Marrabinya, including promoting the PHN Cultural Safety Framework, is a key part of its activities.

The principles in action: What makes Marrabinya work?

Indigenous leadership

Marrabinya was initiated by the Western NSW PHN's Aboriginal Health Council and was developed and is operated by Maari Ma. Marrabinya is staffed mostly by Indigenous people, with its operations overseen by an ACCH governance committee.

Culturally safe

When brokering support services, Marrabinya considers whether the service a client is being referred to is cultural safe.
Marrabinya actively promotes cultural safety to service providers across Western NSW including through implementation of the Western NSW PHN Cultural Safety Framework.

Person-centred and family-orientated

Marrabinya’s model is underpinned by Indigenous people’s right to choose. It places them in the driver’s seat when choosing their healthcare provider, mainstream or ACCHS, and identifying barriers to accessing these services, and works with patients to overcome those barriers.

Integration and continuity of care

Marrabinya works to ensure that their clients’ health care needs are met through providing support to patients and primary care so clients can access the range of services and support they need as per GP care plans.
Local Chronic Care Link Workers are assigned to follow up with the patient and referring GP, providing one point of contact for both.
Marrabinya is building relationships with service providers including ACCHSs and GPs across the Western NSW PHN region. These relationships will support the above.

Sustainable and feasible

The embedding and integration of ACCHSs in the WHAL consortium and PHN Board creates a PHN culture that is strongly supportive of Indigenous peoples’ health care needs and Indigenous-controlled initiatives.
The Marrabinya service model entails staff being co-located in ACCHSs across the Western NSW PHN region. Sharing facilities and office equipment has led to significant overhead reductions and ensures the service is able to maximise resources devoted to patient care.

Pomegranate Health Ep53: Marrabinya – a hand outstretched

Marrabinya is a Wiradjuri word meaning “hand outstretched.” It’s the name of a service in the Western New South Wales Primary Health Network which financially supports Indigenous Australians to attend specialist consultations.