Overview

The Medical Specialist Access Framework addresses Aboriginal and Torres Strait Islander people’s inequitable access to specialist health care by:

  • connecting stakeholders involved in delivering specialist medical care, including patients, carers, communities, funders, facilitators, service providers and individual practitioners
  • following the principles developed in the 2014 RACP Specialist Access Roundtable Consensus Statement
  • focusing on successful models of Aboriginal and Torres Strait Islander people accessing specialist care through case studies

Principles in Practice | Roles and responsibilities | Enablers of Specialist Access


Principles in Practice

The Framework principles are a guide for health sector stakeholders to understand the foundations that need to be in place for Aboriginal and Torres Strait Islander peoples accessing specialist care.

The seven principles inform and support the equitable provision of high quality, effective, accessible, affordable and culturally safe specialist medical care. The Principles are a standard to be considered by funders, facilitators (including Primary Health Networks) and service delivery organisations.

Indigenous leadership

All settings and services should be informed by, and seek to incorporate, Indigenous leaders who are best placed to help shape culturally safe and effective care for the communities they serve.

To make real, long-term gains in Aboriginal and Torres Strait Islander health, the health system needs to recognise the highly skilled leadership of Aboriginal and Torres Strait Islander people who are best placed to mobilise action and build the platform for change in areas of health practice.

Examples of Indigenous Leadership:

Culturally safe & equitable services

Embedding of culturally safe practices in clinical and health care environments across the health system is the way to address inequalities in health access and outcomes for Aboriginal and Torres Strait Islander peoples.

A culturally appropriate health service is one which takes into account local language(s), beliefs, gender and kinship systems, delivers care in a manner which respects these important factors and is free of discrimination.

To address the long-term implications of institutional racism, it is important for health services to undertake an honest evaluation of cultural safety and the competency of its health care professionals.

Use the cultural safety tools and resources to assess the cultural safety of a service.

Examples of culturally safe and equitable services:

Person-centred and family orientated

This principle involves putting patients and their families at the heart of individual and service decisions. Services can be designed to including families in consultations and engage them in the patients care.

It;s particularly important in the Aboriginal and Torres Strait Islander health context, where ‘health’ is often defined broadly and holistically. Health is conceptualised as not merely the absence of disease. Rather, it is a complex and multi-faceted concept, which encompasses the physical health of individuals, social, emotional and spiritual health, and the well-being of whole communities.

Examples of person-centred and family orientated:

Flexibility

The diversity of Aboriginal and Torres Strait islander populations, locations and the differing burdens of disease, means that different health services and funding arrangements may be needed to meet the health care needs of each community specifically.

The adoption of flexible models of care, which are sensitive to the context of care provision and funding availability, to best meet the needs of Aboriginal and Torres Strait Islander populations is a priority for making access to specialist medical care equitable

Innovation and flexibility in service delivery will allow Aboriginal and Torres Strait Islander people choices that take into account cultural and individual preferences.

Examples of flexibility in action:

For information on how to develop a model of care, see Understanding the process to develop a Model of Care a 2013 Agency for Clinical innovation framework.

Sustainable and feasible

Medical specialist services need to be practical and sustainable in the long term in order to have a meaningful impact for Aboriginal and Torres Strait Islander peoples. Long term services create strong relationships with patients and communities.

Long term funding and support allows services to build capacity and provide continuing care. Sustainable delivery of medical specialist care requires direct funding that provides certainty and a degree of flexibility

The distribution of funding for Aboriginal Health is unrelated to population size or need, is not indexed for inflation or service demand, and is not distributed equitably within and between the States and Territories.

See funding initiatives in tools, resources & downloads

Examples of sustainable and feasible services:

Integration and continuity of care

Strong connections between primary, secondary and tertiary health care are needed to deliver effective multidisciplinary care.

Primary Health Care (PHC) is defined as those services that are provided to the whole population (for example, public health and community health services), as well as services initiated by a patient, such visiting a general practitioner. Many health conditions require secondary and tertiary health services as well as PHC.

Continuity of care is needed to ensure appropriate support is available when returning to the community after receiving treatment and to provide collaborative care if the patient’s ongoing care involves multiple health professionals and communication between them.

Continuity of care also refers to the same teams providing care, not simply the same health service, as a patient’s trust and relationship with individual health professionals develops over time.

Contracts and Service level agreements are a means of formalising arrangements between primary, secondary and territory services. Developing appropriate models of care are a means of formalising a patient’s journey between primary, secondary and tertiary health services.

For information on how to develop a model of care, see Understanding the Process to Develop a Model of Care, a 2013 Agency for Clinical innovation framework.

Examples of sustainable and feasible services in action:

Quality and accountability

The right care needs to be delivered in the right way with clear accountability at all levels.

Quality health care and clear accountability are needed to ensure that the limited available funding for Aboriginal and Torres Strait Islander health care is allocated appropriately

Continuous Quality Improvement (CQI) aims to facilitate ongoing improvement by regularly gathering objective data to analyse how well organisational systems are functioning, and implementing process improvements in response to this data. CQI should be in place for specialist care for Aboriginal and Torres Strait Islander Specialist care.

Contracts and Service level agreements are a means of assuring quality and accountability.

Examples of sustainable and feasible services in action:

Videos

 

Roles and responsibilities

There are three key groups of stakeholders with distinct responsibilities involved in the planning, coordination and delivery of specialist medical care.

Medical Specialist Access Network Funders

Funders and employers

This group includes the Commonwealth and State Governments, in NSW only Local Health Districts (LHDs), Local Hospital Networks (LHNs) and hospitals.

Key responsibilities:

  • Funders and employers shape the health landscape through identifying and funding specific health priorities. Funders, as the stakeholder financing the delivery of health services should collaboratively determine appropriate targets and goals for specific populations, noting the issues for ACCHO of excessive reporting and monitoring.
  • The LHNs/LHDs provide a connection to State and Territory governments, and are a critical resource for delivering equitable specialist access for Aboriginal and Torres Strait Islander people. They receive core funding that is weighted for Aboriginal and Torres Strait Islander patients, and often receive funding related to quality improvement and the employment of Aboriginal and Torres Strait Islander Hospital Liaison Officers.
Specialist services are funded by multiple sources. Most non-hospital patient consultations are MBS billable. 

View funding sources

Facilitators

This group includes Primary Health Networks, Aboriginal Community Controlled Health Organisations (ACCHOs), Local Health Districts (New South Wales only), Local Hospital Networks and Non-Government Organisations (NGOs). Facilitators coordinate and commission the provision of care to people and populations at the regional and local level.

For example, the Rural Doctors Network is responsible for administering the Rural Health Outreach Fund.

Key responsibilities of facilitators include:

  • coordinate the provision of care to regions. The planning and delivery of services without coordination can be haphazard, resulting in duplication and ineffective services
  • identify, plan and coordinate the delivery of care
  • meeting the targets specified by funders and ensuring the appropriate health services are arranged and provided
  • underpin the planning and coordination for the appropriate health services is the need for an understanding of: population demographics, health status, available health services, clear roles and responsibilities
  • PHNs are mandated to improve the coordination of care to ensure patients receive the right care in the right place at the right time. PHNs are required to work in partnership to “increase the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes”.1 PHNs have flexible funding available to meet their responsibilities as a facilitator in the health system.
  • ACCHOs play a facilitator role through the coordination of outpatient specialist care delivered in their services2 and in collaborating at the regional level regarding medical care across the care continuum.

Coordinated service delivery will reduce the occurrence of multiple services being unnecessarily delivered to communities and make best use of funding.

See the Primary Health Networks (PHN) 2015 Needs Assessment Guide.

Service delivery and community

This group includes Primary health care services, Aboriginal Community Controlled Health Organisations (ACCHOs), Aboriginal Medical Services (AMSs), Indigenous Community leadership and Aboriginal Liaison Officers (ALOs).

Responsibilities:

  • referring to specialist services and providing ongoing multidisciplinary patient care. An essential factor in effective specialist medical care service delivery is the connection and partnership between primary and secondary care. Specialist medical care is reliant on the conduit and facilitation that primary care services provide, making it easier to connect with Aboriginal and Torres Strait Islander peoples in their communities.
  • Indigenous community leadership is integral to service provision, self-determination for Aboriginal and Torres Strait Islander people in health begins with an engaged local Indigenous Community who are able to provide direct advice and guidance to service providers.
  • the involvement of Aboriginal Liaison Officers (ALOs) Aboriginal Health Workers (AHWs) to is proven to increase cultural safety and have significant impact on the rates of hospital discharge against medical advice in some cases; however, discharge against medical advice is itself understood to be a gauge of cultural safety, so ALOs and AHWs are necessary but not sufficient. They should be considered part of an effective multidisciplinary team and not as an add-on. Involvement of an AHW or ALO does not remove the responsibility of other health professional’s responsibility for cultural needs and considerations.  

Examples of sustainable and feasible services:

Enablers of Specialist Access

The enablers of specialist access are the mechanisms which will assist stakeholders to appropriately fund, plan and deliver medical specialist access for Aboriginal and Torres Strait Islander Peoples.

Organisational capability and health practitioners’ capability

Specialist services are enabled by the health services and health professionals they work with. Health services and health professionals must embody the Framework principle of ‘Culturally Safe & Equitable’. Culturally safe professionals and services must be supported by organisational policies, workforce development opportunities and resources to appropriately engage with specialist health care for their patients.

The responsibility for cultural safety is inclusive—it belongs to each health practitioner as well as each organisation and constituent part of each organisation, all of which must have (and be seen to have) appropriate professional competence, including cultural competence, as well as resources and organisational policies to support this.

Regional Collaboration

Collaboration between funders, facilitators and service providers is required to support the delivery of complete geographical coverage across Australia, regional collaboration should be established based on existing health services geographical boundaries.

The purpose of Regional Collaboration is to enable the Framework principles by:

  • Bringing together the various stakeholders responsible for equitable specialist medical care access for Aboriginal and Torres Strait Islander peoples within a defined region.
  • Providing a mechanism to collectively analyse the health needs of the Aboriginal and Torres Strait Islander populations, determine available resourcing and identify service gaps and unnecessary service overlaps and inefficiencies.
  • Providing a mechanism to plan and coordinate the provision of equitable, principles-based specialist medical care service for identified patient needs.

Identification, Data and Technology

Identification

Information about Aboriginal and Torres Strait Islander patients and potential patients begins with identification. The National best practice guidelines for collecting Indigenous status in health data sets includes guidelines for asking the question, recording responses, and putting the guidelines into practice. Medicare also has a Voluntary Indigenous Identifier scheme, and there are special arrangements for people without documents who can have an approved referee (such as a community elder or minister of religion). A lack of documents may be the result of a lack of birth registration, multiple birth dates and use of different names.

Data

National Key Performance Indicators (nKPIs) for Aboriginal and Torres Strait Islander primary health care data is reported annually. NKPIs provide information about primary health care organisations that receive Commonwealth Department of Health funding and information on chronic disease burden, use of Team Care Arrangements, and detailed information on chronic disease management indicators. These KPIs also point to a service gap via a table comparing nKPI data with statistics for the non-Indigenous population in Australia or with the Australian total (which includes Indigenous people) when appropriate comparison data are available. Such data, along with detailed statistical information about jurisdiction and remoteness variation figures can be valuable for specialist service planning, integration with primary care, and staffing/administration support planning.

Technology

Electronic records are key to efficient recording of patient health information, and efficient and timely access to it. Electronic health records are particularly useful for patients who are mobile and/or have multiple health care providers. They can improve collaboration between health practitioners and between health services, reducing unnecessary duplication of tests (and reduce the inconvenience due to preventable appointments), reduce errors from handwriting, and provide for patient control and engagement with their health. Specific strategies and co-design processes are needed at the My Health Record implementation phase in order to gain the trust and active participation of Aboriginal and Torres Strait Islander people as well as medical specialists. Patients may have concerns about breaches of privacy and confidentiality which could have negative consequences for them and their family.

Telehealth

Telehealth is instrumental in reducing costs of specialist and patient travel, especially in rural and remote areas. It enables the provision of specialist consultations to patients in locations where a specialist is not physically available. Telehealth can be used to respond to inequitable service distribution and reduce travel costs paid for specialist travel, as well as ease the burden on patients, and often their carers, in travelling often long distances to access care. Effective telehealth for Aboriginal and Torres Strait Islander people and communities is an enabler of specialist care but also requires careful planning and education, including the capacity of primary health care practitioners to facilitate telehealth and support patients "at the other end". Telehealth is a useful means of supporting multidisciplinary care and professional development between staff.

Contracts and ​Service ​​Level ​​Agreements (​SLAs)

Contracts and SLAs are the means through which funders can negotiate the provision of services designed to meet targets and goals for specific populations. However, targets and goals need to be appropriate for the context, and must be negotiated collaboratively. Contracts and SLAs can outline specific targets as part of overall deliverables, including specifying timelines. These mechanisms are useful to track multiple stakeholders involved in one area of work and are crucial to monitoring and reporting, which in term assists with managing quality and accountability.

See contracts and SLAs tools, resources & downloads

Meeting the cost of specialist care (hospital and outreach), travel and accommodation

Patients face barriers of various types, including financial barriers, associated with specialist care. The cost of accessing specialist care is an obstacle for patients. The gap between Medicare reimbursement and the service cost varies. Models of care can access funding streams for the amount over and above the Medicare rebate including Closing the Gap grants, PHN commissioning resources, and the Medical Specialist Outreach Assistance Program funding (now incorporated into the Rural Health Outreach Fund). Some successful models of care, such as An Inner-City Hospital Establishes an Aboriginal Health Unit and Reaching Out to Indigenous People in Outer Suburban Brisbane, bulk bill all clinical services delivered in-house or via local outreach.

Patients in regional and remote Australia often need to travel long distances to see specialists and incur accommodation costs in addition to travel. Travel can also mean time away from family, work, and communities, which can be challenging for patients who have family or other care responsibilities. States and territories provide a range of travel and accommodation subsidies, including some specifically for specialist care, and in some cases including subsidies for escorts. Subsidiaries may not include the cost of accommodation for escorts and the cost of patients and escorts traveling between their accommodation and the health service.

Feedback

This Framework will be updated over time, with a second edition planned for late 2018. We will be producing a short Guide for Physicians planned for mid-2018.

Future editions of the Framework will benefit from input and feedback from Aboriginal and Torres Strait Islander leaders, patients, organisations and stakeholders who use this framework and provide feedback to the RACP.

We want to hear from you about potential case studies, especially in areas and specialities not yet covered or that illustrate other elements of the Principles.

Above all the RACP seeks the guidance and advice—from both a health and cultural perspective—of Aboriginal and Torres Strait Islander people who are best placed to mobilise action and build the platform for change in areas of specialist medical care.

Please send any comments, feedback and ideas to indigenous@racp.edu.au

See the Medical Specialist Access Framework for more detail.


[1] Department of Health. Primary Health Networks (PHNs) And Aboriginal Community Controlled Health Organisations (ACCHOS) – Guiding Principles 2016

[2] Couzos S, Delaney-Thiele D, Page P. Primary Health Networks and Aboriginal and Torres Strait Islander health, Med J Aust 2016; 204 (6): 234-237

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