Aboriginal and Torres Strait Islander people face significant barriers to accessing hospital and specialist care across the remote ‘Top End’ of the Northern Territory, where some of the most disadvantaged communities in Australia are found.
The Royal Darwin Hospital works to overcome barriers of distance, culture and language by operating a paediatric outreach service that is responsive to these communities’ health needs, including addressing ‘diseases of poverty’ most often associated with the developing world.
Snapshot | The Top End
The Top End occupies half a million square kilometres of the northern third of the Northern Territory. Darwin has over 100,000 residents, of whom about 1 in 12 are Indigenous. In contrast, about half of the remainder of the Top End’s population are Indigenous. Most live in remote communities of up to 2000 residents. These act as service centres for smaller outstations with between 10 and 100 residents. Many communities have a store, an airstrip, a school, and a health clinic staffed by remote nurses, Aboriginal Health Workers and GPs, who also provide outreach services to the outstations.
The maternal and child health and other gaps
Aboriginal communities in the Top End are among the most disadvantaged in Australia. As is the case for the Indigenous population across Australia, infants, children and young people are the single largest population group. Health challenges can start at birth: rates of low birth- weight births to Indigenous mothers in the NT are three times the national rate. As infants grow into children, overcrowded households, unhygienic conditions and poor diet contribute to childhood ‘diseases of poverty’, which occur at unacceptably high rates. These include chronic otitis media, rheumatic heart disease, trachoma, tuberculosis and scabies. Some can lead to lifelong disabilities if not detected and treated early
The Indigenous health gap and greater need for hospital and specialist services
Indigenous people across Australia, including the ‘Top End’, are hospitalised at twice the rate of their non-Indigenous counterparts.
This is largely due to health-challenging historical, political and social determinants (intergenerational trauma, lack of political power, housing, diet, poverty and essential services) that mean they have significantly greater health needs than other Australians.
This is compounded by lower access to primary health care that would detect ill-health early and result in treatment before a condition might require hospitalisation.
Ensuring Indigenous people are able to access hospital and specialist services is a critical part of closing the health gap, along with addressing these ‘big picture’ underlying causes.
Case study | Royal Darwin Hospital's Paediatric Unit and Outreach Services
The Royal Darwin Hospital (RDH) is the largest in the Top End and NT. The Paediatric Department provides inpatient care for children aged 0–16 in two paediatric wards totalling 36 beds and an 18-bed neonatal unit. There were 4000 paediatric ward admissions in 2017, of which the majority were Aboriginal children. There were 2158 births in 2017, with approximately 710 admissions to the neonatal intensive care unit. Outpatient clinics are run every day at a dedicated paediatric outpatient unit. Careflight operates a 24-hour emergency flight service for Top End communities at distance from the hospital.
RDH Paediatric Outreach (RDHPO) provides outreach to 41 Top End communities via Aboriginal Community Controlled Health Services and Northern Territory government clinics. It also works through the smaller regional public hospitals in Nhulunbuy and Katherine. The RDHPO team includes 11 FTE paediatricians (15 paediatricians in total) and a Paediatric Outreach Clinic Nurse Consultant position.
The Strong Women, Strong Babies, Strong Culture program
The program aims to improve the health and wellbeing of Aboriginal mothers and their newborn babies; strengthen the family unit, and help bring back cultural practices during and following pregnancy.
The program values traditional cultural approaches to parenting and lifestyle, and relies on and supports senior women volunteers to provide direct support to pregnant women and their families. This includes by their attendance at antenatal care clinics and by providing advice on nutrition. Connections and support for involvement in cultural events are an important part of the program.
RDH Paediatric Outreach (RDHPO) provides outreach to 41 Top End communities via Aboriginal Community Controlled Health Services and Northern Territory government clinics. It also works through the smaller regional public hospitals in Nhulunbuy and Katherine. The RDHPO team includes 11 FTE paediatricians (15 paediatricians in total) and a Paediatric Outreach Clinic Nurse Consultant position.
The RDHPO plans, with community health services, to develop an annual visiting schedule, and to ensure mothers, fathers, infants and children are able to attend appointments. By working closely with community-based services, the RDHPO can respond to unforeseen health needs and can reschedule visits that would clash with funerals or cultural events that might affect attendance.
While in community health services, RDHPO staff work with local Strong Women program workers (see Text Box), community Rural Health Service (RHS) staff and Aboriginal Health Practitioners to help ensure a culturally safe service experience. Large family groups often sit in on consultations, and local staff can also to act as translators, cultural brokers and otherwise ensure family child health education.
Captain Starlights (children’s entertainers from the Starlight Children’s Foundation) often attend RDHPO outreach clinics to provide children in waiting rooms with entertainment and encourage their ongoing attendance at outreach clinics. Patients can be mobile between communities, so Paediatric Outreach Clinical Nurse Consultants and RHS staff coordinate with RHSs in other communities to help ensure continuity of care and appropriate follow-up for children with complex health needs.
"There’s a lot of flexibility, which we need otherwise we would miss children that are mobile, in particular when moving between communities and health services"
– Shelley Parker, Paediatric Outreach Clinical Nurse Coordinator
The Principles in Action: What Makes the RDH's Paediatric Outreach Work?
Indigenous Leadership
The RDHPO responds to need identified by local indigenous community health services and Indigenous staff including Aboriginal Community Controlled Health Services (ACCHSs).
Culturally Safe
- Working with Strong Women program workers, community Rural Health Service staff, and Aboriginal Health Workers helps ensure a culturally sensitive link between medical teams and patients.
- Some paediatricians have been visiting communities for upwards of two decades and have gained degrees of cultural competency as a result.
- Diversity, including cultural diversity, between communities is acknowledged and accommodated.
Person-centred and family-orientated
- Captain Starlights ensure a child-friendly environment in outreach clinics.
- Families are encouraged to attend outreach consultations and are educated about their child’s health and treatment.
- Longstanding RDHPO connections to communities includes connections to families and individuals in those communities.
Sustainable and feasible
- Funding – The MBS and Rural Health Outreach Fund provides funding via the NT Specialist Outreach Northern Territory Coordination Unit (SONT).
- Administrative support – The SONT coordinates and provides funds for specialist outreach travel and accommodation that are organised by the RDHPO Outreach Coordinator.
- Institutional culture – the RDH Paediatric Unit has a longstanding commitment to outreach. This is built into specialists’ and registrars’ job descriptions and schedules. Registrars only visit communities with specialists who know the communities well.
Integration and continuity of care
- Mobile patient’s healthcare is coordinated by the RHS.
- eHealth records are used where possible.
- Longstanding RDHPO-relationships with families and individuals helps ensure continuity of care for them.
- Working with Strong Women program workers, community Rural Health Service (RHS) staff, and Aboriginal Health Workers has the added advantage of helping ensure treatment and adherence in between RDHPO outreach visits.
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Read next: Building an Outreach Program in Remote Indigenous Communities