1. Health care access for Aboriginal people living in urban areas. David Scrimgeour May 16th 2007

2. NACCHO 2001 There is often a misconception among policy makers, and indeed, the general public, that efforts should be directed to Aboriginal people in remote areas only, as Aboriginal people in urban areas are not seen as having the same level of need. This myth needs to be overcome. Aboriginal people in all areas – urban, rural, and remote – experience similarly poor health status.

3. Where do Aboriginal people live? Major cities 30.1% Inner regional 18.7% Outer regional 23.2 % Remote 9.1% Very remote 18.9%

4. Features of urban Aboriginal populations Heterogeneity Mobility Dispersion throughout urban areas “Invisible minority” Identity issues

5. Mortality gradient (from Glover J, Tennant S and Page A. The impact of socioeconomic status and geographic location on Indigenous mortality in Australia 1997-99 Occasional paper series 1, 2004, Public Health Information Development Unit, Adelaide.)

6. Historical background 1971 Redfern AMS Aboriginal community controlled health services “Mainstreaming”

7. Mainstreaming “In urban areas at least, the urgent priority should be on meeting the needs of Indigenous people through better access to mainstream services.” -We can do it! Report of the HRSCATSIA 2001

8. Mainstreaming “The majority of Indigenous Australians live in cities and towns where good services, education and employment are available. Too often Indigenous Australians … do not access these services … Setting up parallel services in these places, often with lower standards and expectations, has not produced the results that organisations like ATSIC sought to deliver … Our approach will be to facilitate access to all services, rather than establish alternatives.” -Minister Mal Brough, December 2006

9. Mainstreaming: Commonwealth Grants Commission inquiry into Indigenous funding 2001 It is clear from all available evidence that mainstream services do not meet the needs of Indigenous people to the same extent that they meet the needs of non-Indigenous people. Indigenous Australians in all regions access mainstream services at a very much lower rate than non-Indigenous people. Mainstream programs provided by the Common- wealth do not adequately meet the needs of Indigenous people because of access barriers.

10. Mainstreaming: Commonwealth Grants Commission inquiry into Indigenous funding 2001 Commonwealth Indigenous-specific programs are intended to provide targeted assistance to Indigenous people to supplement the delivery of services through mainstream programs … the failure of mainstream programs to effectively address the needs of Indigenous people means that Indigenous-specific programs are expected to do more than they were designed for.

11. Recent developments Primary Health Care Access Program (PHCAP) Improved access to Medicare through EPC items and other initiatives Urban brokerage

12. Economic aspects Total health expenditure per capita for Indigenous people in urban areas is lower than for Indigenous people in remote areas and lower than for urban non-Indigenous people. Per capita expenditure for Indigenous people is 1.6x higher for admitted hospital patients and 1.9x higher for non-admitted hospital patients.

13. Hospital statistics Higher hospitalisation rates for ‘ambulatory- sensitive’ conditions (several studies). Medical admissions higher; admissions for surgical procedures lower (Ishak 2002). Higher rate of surgical admissions through ED (Ishak 2002). Lower rates of procedures among hospital patients (Cunningham 2002, AIHW 2005).

14. Importance of PHC (Starfield et al 2005) Supply of primary care physicians significantly associated with lower all-cause mortality, but supply of specialists is associated with higher mortality. Supply of primary care physicians less closely related to health of urban African- Americans than for urban whites or rural African-Americans.

15. Primary care physicians used by urban Aboriginal people GPs ACCHSs Community Health Services Emergency Departments

16. Diversity of PHC providers for urban Indigenous Australians (Cunningham ANZJPH 2006) 45% private GPs (most-named practice <6%) 32% ACCHS 11% ‘nowhere in particular’ 5% community health centre 1.5% public hospital “Although ACCHSs must clearly play a leadership role in driving improvements in Indigenous health, the diversity of services and practitioners … indicated both the need – and the likely opportunity – for all health care providers to play a part in improving and maintaining the health of Aboriginal and Torres strait islander Australians.”

17. Aboriginal views on access WAACHS: Primary carers of Aboriginal kids less satisfied with health care access than non-Aboriginal counterparts; urban carers less satisfied than rural and remote carers. Craig 2002 (SW Sydney): Most people happy with care they received from GP, but 4 major barriers identified: Financial barriers; transport; communication; shame.

18. ED utilisation (Thomas & Anderson 2006) Attendance at EDs 2x greater; Waiting times similar; Higher rates of walking out before being seen; No evidence that ED is used a substitute for other PHC; “more important than questions about whether substitution is occurring are questions about whether this substitution leads to better or worse medical care”

19. GP consultations  2003 BEACH Report:  1.4% of consults involved Indigenous people (2.2.% of population);  Number of problems managed per encounter same as for non-Indigenous people.  Thomas et al, Darwin (1998), Larkins et al, Townsville (2006):  More problems managed per encounter with Indigenous patients in ACCHSs compared to mainstream general practice.

20. Rogers et al MJA 2005: Care and Prevention Programme Not sustainable with current MBS as only source of income. The financing gap arose from an interacting array of factors, including: The proportion of patients who are bulk-billed; The complexity of patient needs; GPs not compromising on best practice, leading to longer consultations and hence a lower MBS rebate per hour;

21. Rogers et al MJA 2005: Care and Prevention Programme (cont.) The need for support from a trained nurse; The effect of a culture that that accepts ‘long consultations’ on the duration of consultations practice-wide; The strategy of some patients to see doctors only when they have more complex requirements, rather than for shorter consultations which would increase the practice’s MBS income per hour, & The additional costs of training staff.

22. Craig 2002, SW Sydney Difficulties experienced by GPs in establishing trust: requires long consultations and ‘the system is against it’. Some GPs specifically mentioned that they do not get involved in mental health or drug and alcohol issues.

23. Particular health issues with problems of access Dental health; Addictions; Mental health

24. Sub-populations with particular needs ‘Homeless’ Visitors from remote communities; People in or recently released from custody; People recently discharged from hospital; Youth; Torres Strait Islanders

25. Barriers to access Availability Affordability Acceptability Appropriateness

26. Davis K, Editorial, New England Journal of Medicine, March 15 th 2007 “The fee-for-service system of provider payment is increasingly viewed as an obstacle to achieving effective, coordinated, and efficient care. It rewards the overuse of services, duplication of services, use of costly specialized services, and involvement of multiple physicians in the treatment of individual patients. It does not reward the prevention of hospitalization or rehospitalization, effective control of chronic conditions, or care coordination.”

27. MBS reforms Urbis Keys Young Report 2006: Increased Aboriginal enrolment in Medicare. Increased claiming of rebates on behalf of Aboriginal people. ?? Improvement on morbidity and mortality.

28. What are the best structures for improving health care access for urban Aboriginal people? ACCHSs Community Health Services ?? fee-for-service GPs ???? GP “Plus”

29. Questions or comments? Health care access for Aboriginal people living in urban areas.