Outreach does not necessarily involve travelling long distances to remote communities.
Snapshot | Melbourne's Indigenous Population
History
The five peoples of the Kulin Nation have occupied the Melbourne area for tens of thousands of years. Melbourne itself was established in 1836. Most of Victoria’s Aboriginal peoples were confined to reserves by the late nineteenth century. Those looking for work began to return to the inner-city Melbourne slums of Fitzroy and Collingwood during the Great Depression. By the 1960s, these areas held significant Aboriginal communities.
Population today
In 2016, Melbourne’s Indigenous population was just over 24,000 people strong - about half of Victoria’s Indigenous population. With Fitzroy and Collingwood’s gentrification, much of Melbourne’s Indigenous community is now spread across suburban areas. Over one in three of Victoria’s indigenous population are under 15 years of age compared to one in five of the non-Indigenous population.
The significant health needs of Indigenous people in inner city urban areas are often overlooked, and there are opportunities for specialists and their hospitals to work in inner cities in partnership with Aboriginal Community Controlled Health Services.
It is noteworthy that almost one in three Indigenous people are under the age of 15 years, compared to one in five of the non-Indigenous population. Yet Indigenous maternal, infant and child health is significantly worse. Outreach by paediatricians, ENT specialists, child psychiatrists, and so on, is vital to closing the indigenous health gap and ensuring the future Indigenous adult population has the best start in life1.
Victorian Aboriginal Health Service
Fitzroy had become a hub of the Aboriginal rights movement by the 1970s. In 1973, the Victorian Aboriginal Health Service (VAHS) was established there as the first Aboriginal Community Controlled Health Organisations (ACCHOs) in Victoria. Today, VAHS operates across four Melbourne sites and is actively involved in outreach across Melbourne. It supports walk-in appointments, a transport service and home visits for eligible clients. VAHS provides a comprehensive range of physical health, mental health, social and emotional wellbeing, dental and social support services. Many staff have deep community ties. The Fitzroy centre remains a hub of community life and VAHS supports community activities. Twenty-four ACCHOSs have now been established across Victoria; VAHS acted as the ‘mother service’ and assisted with the establishment of the ACCHOSs in the state2. In 1996, the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) was established as their peak body.
The maternal and child health gap
Maternal and child health has been an ongoing focus of VAHS and other Victorian ACCHOs. Despite decreases in the rate of low birth weight babies born to Victorian Indigenous mothers and Victorian Indigenous child immunisation rates being among the highest in Australia, there is still a significant gap in Victorian Indigenous mothers accessing antenatal care in the first trimester of pregnancy, rates of low birth weight babies and infant mortality, when compared to the non-Indigenous rates.
“ If I haven’t heard from a patient for a while and they live near me, I’ll drop in on them on my way home”
– Susan Hedges, VAHS Family Programs Coordinator
What is an Aboriginal Community-Controlled Health Service (ACCHS)?
An ACCHO is a comprehensive primary health care service initiated, operated and controlled by local Aboriginal communities through a locally elected board of management. ACCHOs vary in size and the services they deliver, but all aim to deliver a model of care aligned with Aboriginal culturally shaped and holistic concepts of health. By this, the health of the ‘whole Aboriginal person’, including their mental and physical health, and their connections to family, community, culture, country and the spiritual dimension of existence, are accounted for3. The concept of Social and Emotional Wellbeing recognises the contribution of the historical, political and social determinants to Aboriginal health. Models of care include social support as required, such as housing, employment and advocacy in broad terms.
ACCHOs are culturally safe and ensure culturally competent consultations and treatment are core business, by providing a culturally safe environment governed by community members and employing Aboriginal GPs, Aboriginal staff and Aboriginal Health Workers. They also bulk bill to remove any financial barriers to health services. Many, such as VAHS, operate outreach and transport services to reduce barriers of distance, and provide access to affordable and appropriate services. Researchers report that where an ACCHS exists it is the preferred provider of health services to local Aboriginal communities4, and they outperform other health services in many areas5.
Case study | Reaching out as a team member of VAHS' Women's and Children's Unit
Specialist outreach
Paediatricians, a general and colo-rectal surgeon, general and interventionist cardiologist, geriatrician, ophthalmologist, ENT specialist and dermatologist provide outreach services at VAHS and some specialists are employed directly by VAHS. They are based at Melbourne’s Royal Children’s Hospital, St Vincent’s Hospital and the Royal Victorian Eye and Ear Hospital and are released by these hospitals to provide services at no cost. VAHS employs two staff paediatricians who work a combined today of 0.8 FTE. At present, VAHS does not receive any funding to cover the cost of specialist paediatric services.
VAHS Women's and Children's Unit
The VAHS’s Women’s and Children’s Unit currently sees about 900 local Indigenous children. The multidisciplinary core team aims to provide a comprehensive and holistic service, and includes general and adolescent paediatricians, a midwife, a speech pathologist, Aboriginal Health Workers (AHWs), a Care Coordinator and an in-home support worker. Unit intake meetings with all staff involved occur on Monday mornings to coordinate and plan referrals and ongoing care for children. Outreach services include speech pathologist clinics conducted at schools and annual health checks conducted at child care centres. The Unit also provides care for children in out-of-home care. Paediatricians participate in child protection meetings, identify health issues and request brokerage funding if necessary (see below). Advocacy for children in out-of-home care, including with government agencies, is an important part of VAHS’s work, to help achieve the best outcomes for these children.
"Families and children want to be seen where they feel safe"
– Dr Niroshini Kennedy, Paediatrician
The Principles in Action: What Makes the RDH's Paediatric Outreach Work?
Indigenous leadership
Indigenous leadership occurs through specialists working with and through VAHS under an ACCHS-model of care that ensures Indigenous leadership and control of services.
Culturally safe
- VAHS is a culturally safe environment. VAHS’s clients are more likely to attend specialist consultations taking place at VAHS than those in hospitals.
- Aboriginal Health Workers attend specialist consultations and can act as cultural brokers, even translators, for patients.
- Working at VAHS over time enables specialists to better understand and work with cultural differences.
Person-centred and family-orientated
Family members are involved in patient consultations, recognising the importance of family support and involvement in child healthcare.
Integration and continuity of care
- Building relationships with patients, families and communities – building trusting, long-term health care service and professional patient relationships are key to success in outreach work.
- Team work – partnership with VAHS’s staff, including by case conferencing, helps ensure holistic, integrated care and builds the capacity of VAHS staff who learn from working with specialists.
Sustainable and feasible
- Institutional culture – VAHS has longstanding and positive relationships with the three hospitals who release specialists for outreach work. These hospitals are committed to reconciliation through their Reconciliation Action Plans and employment of Aboriginal Hospital Liaison Officers (AHLOs). These work with specialists in hospitals when seeing Indigenous patients.
- Funding is a challenge – VAHS is not funded to cover the costs of specialists’ services.
Wadja Aboriginal Family Place
Hospitals can also work to improve the health of local Indigenous communities by improving Indigenous patients’ hospital experiences. The Royal Children’s Hospital includes the Wadja Aboriginal Family Place. Staff there, including AHLOs, provide support to Indigenous families to attend outpatient clinics or emergency departments, or to families who have a sick child in hospital. They do this by providing emotional, social and cultural support, and by ensuring families and children understand medical procedures and routines. They also raise awareness within the hospital to help ensure that a culturally sensitive service is provided. See also the case study on St Vincent’s Hospital’s Aboriginal Health Unit.
Would you like to reach out to an Aboriginal Community Controlled Health Service?
There are opportunities for specialists and their hospitals to work in partnership with ACCHSs in urban or remote settings. The National Aboriginal Community Controlled Health Organisation (NACCHO) is the national ACCHS peak body and its members include VACCHO.
"Paediatricians are an integral part of the team. There is heaps of learning for staff working with the paediatricians, staff can ask for a laymen’s explanation if they don’t understand which helps families understand as well. It’s a two-way learning process, paediatricians learn about connections in communities and family relationships.
"Patients have said that it's a like a one-stop shop, they prefer to come here rather than going through the hospital system.
"Some community members don't know what a paediatrician does, so we talk to families about what paediatricians do so families feel comfortable seeing them. Getting the right onwards referrals from paediatricians helps families get the care their kids need".
– Margie Davidson, Team Leader at the Women's and Children's Unit
"I trained in Community Child Health, a branch of paediatrics that deals with the health, development and wellbeing of children, in the context of family and community factors. The aim is always to provide holistic, patient-centred care in a culturally appropriate way. Here at VAHS, I am able to use my skills, and provide this while being integrated into a multidisciplinary team, and this is enormously rewarding.”
– Dr Niroshini Kennedy, Paediatrician
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Read next: Reaching Out to Mums, Bubs and Children in ‘Top End’ Communities
1 Aboriginal and Torres Strait Islander Health Performance Framework Report (PDF), 1.20 Child and Infant Mortality, Department of Prime Minister and Cabinet, 2014.
2 Members, Victorian Aboriginal Community Controlled Health Organisations.
3 'A national Aboriginal health strategy', National Aboriginal Health Strategy Working Party, Australian Government, 1989.
4 Victorian Aboriginal Health Service Annual Report 2017–2018 (PDF), Victorian Aboriginal Health Service, p 15, 2017.
5 Panaretto KS, Gardner KL, Button S, et al, Prevention and management of chronic disease in Aboriginal and Islander Community Controlled Health Services in Queensland: a quality improvement study assessing change in selected clinical performance indicators over time in a cohort of services, BMJ Open, 2013.