Closing the gap in health equity

Dr Charlotte Middleton (00:15):

Universal Healthcare is one of the cornerstones of the Australian way of life. It’s built on the principle that every Australian should have equal access to quality healthcare based on medical need, not the size of their wallets, their post code or their ethnicity. However, our health statistics tell another story.

Dr Charlotte Middleton (00:35):

The Australian Institute of Health and Welfare found that one million Australians are putting off seeing a doctor because they can’t afford it. We know that people living in rural and remote areas, experience poorer health outcomes, and lower access to healthcare services. And lower socioeconomic groups experience higher instances of obesity and other chronic illnesses. It’s estimated that 80% of health outcomes are affected by social, economic and environmental factors. What does healthcare look like for Australians today? Is our healthcare system becoming unaffordable and inaccessible? Is this a government problem alone? Or can we, as healthcare providers, do something to help close the growing gap? Joining me today is Dheepa Jeyapalan, former advisor to CEO, Victoria Health. Hi, Dheepa.

Dheepa Jeyapalan (01:27):

Charlotte, great to be here.

Dr Charlotte Middleton (01:30):

Stephen Duckett, director of health programs, Grattan Institute. Hi, Stephen.

Stephen Duckett (01:34):

Charlotte.

Dr Charlotte Middleton (01:36):

Karl Briscoe, proud Kuku Yalanji man from Far North Queensland and CEO of the National Association of Aboriginal and Torres Strait Islander health workers and practitioners. Hi, Karl.

Karl Briscoe (01:50):

[inaudible 00:01:50]. Thank you for having me.

Dr Charlotte Middleton (01:53):

And Professor Carla Treloar, director of the Center for Social Research and Health and the Social Policy Research Center, UNSW. Hi, Carla.

Professor Carla Treloar (02:02):

Hi, Charlotte. Thanks for this great conversation today.

Dr Charlotte Middleton (02:06):

Yeah, well look, thank you so much to all of you for taking the time out to join me today on what is obviously an extremely important topic that needs to be discussed out in the wider medical community. Let’s start talking about the impact of COVID itself. It really has thrust health equity into the spotlight, is it magnifying the profound impact that social, economic and environmental factors can have on our health and wellbeing. Did it really take a pandemic to bring it to light? I might start with you, Dheepa, given, in Victoria, you’ve obviously been the worst affected of all of us, by COVID.

Dheepa Jeyapalan (02:41):

Thank you, Charlotte. And yes, we’ve been struggling through a difficult couple of years. And what we’ve seen is that it has not been the same experience for any two people across the state. It did bring these, you’re completely right, it did bring health equity into the spotlight, and we need to make sure that it stays there to interrogate these unjust and unfair differences that people have faced. So the pandemic demonstrated the impact of the social determinants of health. Many of us who work in the health sector learn about the social determinants of health. In our first years of studies, at times it can get lost in all the clinical and other technical knowledge we are taught, but the pandemic showed us that we need to keep this center of mind in our practice.

Dheepa Jeyapalan (03:24):

So we saw that people who had insecure work, unfair housing, which area you lived in, your financial situation, your cultural background, all determined whether you were likely to get COVID and how you survived through it. At Vic Health we did our own surveys of, our population-wide survey. Before the pandemic, during that first lockdown period that we had last year, and then following that as well, we saw that some people thrived during the pandemic. Some people were able to save money because of the work they did and where they lived. They were able to spend more time with family, cook more, do some gardening, and they actually found a new way of living that they enjoyed. Whereas others were more financially distressed, were socially disconnected, were feeling just a sense, overwhelming sense of grief throughout that period. So these two different experiences showed us how inequitable achieving good health can be and why we need to keep talking about health equity. So it’s great that we’re having this conversation.

Dr Charlotte Middleton (04:25):

What a fantastic summary. I think we’d all agree with that. Did anyone have anything to add to that?

Professor Carla Treloar (04:32):

Yeah, I’ll add a bit. Work we’ve done with ACOS has showed that the communities that were economically disadvantaged prior to COVID, were those that had higher rates of people reliant on the lowest income supports during 2021. And so this is a concern in terms of health equity, of what happens in 2022 and beyond, if there are certain communities or areas across our countries that are really struggling, for people to find work again? And what that does to their choices that they can make about health prevention, going to see GPs, et cetera. So this isn’t over yet. We have a long tail here of what could impact on particular communities. Those that were struggling prior to COVID are still struggling now, and maybe more so.

Dr Charlotte Middleton (05:29):

I feel, Karl, you probably have something to say about this as well.

Karl Briscoe (05:33):

So Aboriginal and Torres Strait Islander leaders have been raising the issue of health and equity, and the need for holistic joined-up approaches to address the social, cultural and environmental determinants of health and wellbeing for many, many decades. Given the recent years, the whole of government failure for us, that the pandemic has served us once again, to amplify the issues, bring systemic racism and inequality that exists within our country, back into the spotlight, and place our families and communities at extreme and heightened risk. However, despite the unfair barriers put in our way, the pandemic also continues to bring greater attention and focus, and strengthen the capacity of our leadership and the critical nature of Aboriginal and Torres Strait Islander- led and delivered responses. The way we partnered with government to successfully keep people, our people, safe at the start of the pandemic, compared to the more recent responses to the outbreak in Western Houston, South Wales, for example, demonstrates a need to stand with us, to hear us and support our leadership.

Karl Briscoe (06:57):

Prior to COVID 19 reaching our shores, we understood the risk and we knew our communities were vulnerable and at elevated risk of serious infection and mortality. We raised issues of geography, overcrowding, the need for culturally safe responses, health services’ capacity and awareness. We exercised our leadership and we worked collaboratively to develop responses, mobilize our networks and harness support.

Dr Charlotte Middleton (07:31):

Yeah, fantastic summary there as well for your communities. And as, Dheepa, you alluded to, there’s some positives, but a lot of negatives as well that’s come out of that, COVID. Stephen, I might ask for your thoughts on this.

Stephen Duckett (07:48):

So Charlotte, the equity issues hit at every point. We saw stories in New South Wales where vaccination centers were unevenly distributed. Fewer vaccination centers in low socioeconomic class areas, more in wealthy areas. The jobs that people on lower incomes had, exposed them more so that … I’ve got a friend who’s an emergency plumber, or the son of a friend who’s an emergency plumber. And then he had to go to five houses in one day, increasing his exposure, whereas I could work at home and not be exposed. And so we saw, time and time again, the uneven nature of the exposure, the uneven nature of the prevention and the consequential uneven nature of vaccination rates. Government didn’t engage with communities to boost vaccination rates in time, et cetera, et cetera. And so COVID was a microcosm, a spotlight, on the underlying problems we have already in the health system.

Dr Charlotte Middleton (09:00):

Yeah, just amplified them all, really, as you’re saying. Carla, I might just ask this of you in terms of the role that healthcare data has in providing better access to those who need it. Can sharing data and evidence across the main sort of social determinants of health, help us to find smart ways to achieve better health outcomes?

Professor Carla Treloar (09:23):

Absolutely. The better, more detailed picture we can build around a community or a person’s health, wellbeing, is the best way to engage in great solutions. So this just doesn’t mean the clinical variables that might be collected in the GPs office, it means issues of where they’re living, how they’re living, types of income they have, gaps in being able to do the things they want to, in relation to protecting and promoting their health and that of their family and community. So it is a challenge though, to look across big data sets or big views of the world, and say to funders of services or governments, this is a joined-up, Karl’s words there were great, this is a joined-up picture that we should be looking to, to really understand how we can deliver best health interventions that are really based in a structurally competent view of the world. That we understand the ways in which income, race, gender, geography, position in society, affect the choices that are available to people to protect and promote their health.

Dr Charlotte Middleton (10:38):

Yeah. And to Stephen’s point too, talking about his friend’s son who is a plumber. Understanding people’s job descriptions and therefore where perhaps we need to focus vaccination hubs so that they can then continue their work as essential services, that sort of thing. It’s hugely important.

Professor Carla Treloar (10:58):

Absolutely. And some health practitioners might think, that’s outside my role. What do people’s jobs have to do with me? But people don’t live their lives in these little narrow containers that we might like to structure services around. People have their lives as messy and complicated and wonderful as they are. And we need to be working in that space to really deliver effective solutions for people, that make sense, and they can act on.

Dr Charlotte Middleton (11:28):

Couldn’t agree more. Just looking to the affordability of healthcare. We know that it’s increasingly becoming more unaffordable, despite the fact that most Medicare, a lot of Medicare services are bulk billed, and that can be anywhere for sort of 81 to 87%, depending on what year you look at. Ten percent of our GDP is spent on healthcare, yet many Australians are still paying out of pocket for Medicare services. And Australia is actually at the highest end of the OECD average for what individuals pay for their healthcare. So what does this say about health equity in our country? Stephen, I might get your views on this.

Stephen Duckett (12:09):

So thanks, Charlotte. There are a couple of points. As you point out, there is a very, very high rate of bulk billing in this country, 90% or so of all services are bulk billed. But only about two thirds or so of all people have all of their services bulk billed. So depending on who you are, you have a very different experience. What we have to worry about is that, one of the things we have to worry about, is that access to services, general practice, specialist services, for example, is very uneven in terms of financial barriers. So if I live in rural or remote Australia, I have less access to seeing a bulk billing specialist. If I have a chronic illness, I spend much more of my income on healthcare than if I don’t have a chronic illness. And not only that, but if I’ve got a chronic illness, I’m more likely not to see a doctor when I thought I needed it than if I don’t have a chronic illness.

Stephen Duckett (13:15):

So the very people that we want to make sure have no financial barriers, namely people with chronic illness, are the ones that face financial barriers with, despite decades of policies about expanding access to services in rural remote Australia, we still have financial barriers there. So yes, Medicare is a fantastic underpinning, but it needs to be improved. We need to be addressing these out-of-pocket costs for access to general practice and specialist services. And there are ways to do it. Sometimes the gap between the level of the bulk billing and the level of out-of-pockets is quite small. So we could just say, everybody’s going to bulk bill if they want to be in Medicare, or something like that. So we’ve got ways we can address these things, and we have chosen not to address them.

Dr Charlotte Middleton (14:05):

Yeah, look, I’ve got my own views about Medicare and the rebates, which I’ll probably bring up a bit later, but Karl, I could see you nodding there a lot. Did you want to have a word?

Karl Briscoe (14:15):

Yeah. I think it’s really important to understand that some groups in our society, such as Aboriginal and Torres Strait Islander people, there has never been health equity. And for these groups, healthcare in Australia is becoming increasingly unaffordable. In attempting to address issues negatively impacting upon the delivery of primary healthcare to Aboriginal and Torres Strait Islander clients, an Aboriginal Torres Strait Islander health reference group provided a series of recommendations to the MBS review, conducted in 2015 to ’20. Significantly, this group recommended that the expansion and/or extension of many MBS referral and follow up pathways to enable complex chronic conditions to be addressed through a holistic continuum of care through the life course. Whilst 13 of the 17 reference group recommendations were endorsed, only two were fully endorsed, with the remaining 11 supported in principle. So the statement on how and when action will be taken to address these recommendations has not been forthcoming thus far. And the delay in progressing the reference group recommendations is jeopardizing health improvements and wellbeing outcomes for individuals and our communities.

Dr Charlotte Middleton (15:55):

Yeah, it’s a real worry, isn’t it? So much more to be done. All right. Well, let’s look at the research that absolutely shows lower socioeconomic groups have higher incidences of obesity and other chronic illnesses, such as type 2 diabetes. For example, north New South Wales, Western Sydney, is recognized as a hotspot for diabetes. We’ve had twice the incidence of diabetes compared to northern and eastern suburbs. How could we use data like this to improve outcomes? Carla, I might start with you on that.

Professor Carla Treloar (16:30):

I think the most important thing not to do with data like that, is use it as a stick and say, these communities are lacking or deficient, or whatever other negative term that we can use. I think the broader view of health equities to think about, what is it about these communities that could be shaping these outcomes? So what is it about availability of green space to go for a walk versus having to pay for expensive gym fees? What is it about fresh food availability that’s important to understand? What kinds of community supports are available for educating people about food choices or activity or monitoring? What’s the champions of good health that we can mobilize in communities, particularly where English might not be the first language? And there are different cultural views around food and family and gathering and celebration as well.

Professor Carla Treloar (17:27):

So these data are great. We live in a very data full world in some ways, but data can be used really problematically. Allowing communities to look at that data themselves, make sense of it, understand how it fits to their world and the solutions that they can see for themselves, is the way to go here. I think looking forward, the example of Western Sydney is really interesting about climate change and what raising temperatures might do for people’s ability to get out and go for a walk, in periods of year where it’s really inhospitable to be outdoors. So this casts a really broad view on how to manage something that’s quite narrow, like diabetes or overweight, but it’s again about understanding how an individual and their community lives with themselves and each other, and in the spaces they have available to them and what health infrastructure is there, as well as broadening that definition of health infrastructure, in this case to think about space for exercise, food, fresh food availability, and so on.

Dr Charlotte Middleton (18:38):

Yeah, it gets back to what I’m passionate about, which is looking at prevention rather than waiting for people to get sick in the first place. Let’s look at how we can prevent illness in the first place. And I personally don’t feel there is nearly enough emphasis or resources given to that as a whole. Dheepa, you’re dietician, obviously you’d have something to say about this.

Dheepa Jeyapalan (19:02):

Definitely. And I agree with everything Dr. Carla, Professor Carla, sorry, and Dr. Charlotte have said. Completely agree that the way that we use this data is really important. So using the data, but also using data that explains why these issues exist. So for example, as a public health dietician, I think about, what are the barriers that people face to accessing and enjoying nutritious food? So maybe you think about a family that live in an area closer to this city, in Sydney, in a wealthier suburb. Parents may have jobs that are flexible. They don’t have a long commute. They make a good enough wage to be able to put healthy food on the table. There may be some barriers to them cooking and enjoying nutritious food. They may be busy because their kids have a lot of activities, but that’s just one barrier that they face to enjoying and accessing nutritious food.

Dheepa Jeyapalan (19:51):

If you compare that to a family that live in Western Sydney, and I’m not trying to generalize or stereotype people at all here, but they may have parents that have to travel far distances to work. English may not be their first language, the supermarket’s complicated, and they’re not sure what is healthy and unhealthy. All of us understand how complicated the supermarkets can be. So when you slowly interrogate that, you realize that there’s 10 to 20 barriers to them having a nutritious meal at dinner. So then that’s where data should come into play, for us to figure out what are those barriers that exist? And in our practice, we should be focused in dismantling those barriers so that having a nutritious meal for dinner is not a far off dream, but an easy and accessible reality for more families.

Dr Charlotte Middleton (20:36):

Fantastic. Thanks for that. Karl, I might ask this one of yourself. We know that people in rural and remote communities are less likely to see a GP due to physical access, and we have already touched on that. Now, the rise of Telehealth during the pandemic, we obviously would all agree has been a huge step, and in the right direction. What other technologies and tools do you think we could be utilizing to support healthcare in rural and remote communities?

Karl Briscoe (21:05):

Yeah, with over 600,000 instances of Telehealth services since the start of the pandemic, it’s clear that Aboriginal and Torres Strait Islander people and our health workforce, including those in rural and remote communities, have embraced technology as a means of accessing and continuing healthcare plans. For Aboriginal and Torres Strait Islander people specifically, with our border and broader and more holistic focus on health, it’s worth noting that the critical components of accessibility to health services are generally less about geography, though that does play a role, and more in terms of culturally safe access to healthcare services. The pandemic has demonstrated the way in which digitalization creates more room for miscommunication. It’s absolutely critical that we recognize how it exacerbates the risk to patient safety and engagement, and find ways to ensure the quality and safety of healthcare is not compromised as we move into the digital age. From my understanding, the new primary healthcare plan currently under development includes a focus area on using technology to drive improvements, to support safe quality Telehealth and virtual healthcare, improve the way in which data is used, and digital integration, and harness advances in healthcare technologies.

Karl Briscoe (22:59):

As this plan is implemented, we maintain and expand the suite of Telehealth pathways available. We need to have assurances that these digital spaces are culturally safe. Advances in healthcare technologies, such as the adaption of genomics, precision medicine and point of care testing also have the potential to improve efficiencies and effectiveness of the healthcare system. To improve the health equity, eventual upscaling of technologies should be prioritized investment in rural and remote areas. This includes additional investment in basic IT infrastructure and the workforce required to roll it out.

Dr Charlotte Middleton (23:54):

Yeah. And your last point is very relevant, and that’s what I was actually going to say as well. I think we, as Australians, are all willing to embrace digital technologies, but unless the infrastructure supports it, particularly in those rural and remote communities, trying to do a video consult, it’s just not going to happen. But we know that, you alluded to the fact that trying to speak to someone through the telephone can be very difficult, you don’t get those normal cues. So at the very least, having video consults available can make a big difference. But if you don’t have the infrastructure to support that, then you’re going to find that, it’s not going to be as effective. So it’s such a much broader picture as well, that needs to underpin all of this. Did anyone else have anything to add to that?

Stephen Duckett (24:42):

Well, now you ask, Charlotte. I’m an enthusiast, and we mustn’t forget that the Telehealth initiatives, Australia has been slow in, at the Commonwealth level in this area, the states have done a lot. Queensland has done a magnificent amount on Telehealth over the decades. But if I just give you a story. My daughter lives in London and she has a choice of whether she sees the GP or has a Telehealth consultation. The virtue for her is if the Telehealth consultation is at quarter past 10, that’s when the GP rings. There’s no wait in the waiting room, it’s absolutely there. And then, you know that you’ve got this time and the time is well scheduled. And so it’s so much more convenient for patients.

Stephen Duckett (25:38):

And I think we shouldn’t forget about that benefit, as well as being able to, in a sense, be a triage. What can be done? I take Karl’s point, not everything can be done on Telehealth. What can be done on Telehealth should be done on Telehealth, in my view, but what can’t be done, shouldn’t be done. So it’s an issue that the consumer and the provider need to agree, that this is okay for telehealth, and this is not.

Dr Charlotte Middleton (26:06):

Yeah, look, I mean, personally, as a GP myself, Telehealth has been a game changer. And I think for all of us, we would agree that none of us wanted to go anywhere, but we have to use it where appropriate and understand where it perhaps isn’t as appropriate in our consults.

Dr Charlotte Middleton (26:25):

Stephen, just sort of moving into the next question. It’s a good segue into … Do we think that we’re creating two tiers of potential healthcare, those digital haves and digital have nots, people that can access digital health versus people who can’t?

Stephen Duckett (26:41):

Yeah. So we started this conversation with this issue of equity and we don’t want to exacerbate equity issues with Telehealth, but Telehealth, we need to think about what are the mechanisms to ensure that there is appropriate Telehealth access. And in rural or remote Australia, that’s going to be particularly challenging. And that’s also one of the areas where it can be particularly beneficial because you don’t have to travel so far, either the provider or the consumer, and so on. So yes, but all that says is, we have to think about how we address the issue of digital equity and how we ensure that what we do, doesn’t exacerbate inequity rather than provide a solution to it.

Dr Charlotte Middleton (27:32):

Absolutely. Karl, let’s look at indigenous health again. We know that indigenous Australians have a life expectancy 10 years less than non-indigenous Australians, driven in part by lack of access to healthcare. The national agreement on closing the gap was unveiled by the government in July 2020, and outlined strategies to, and I quote, “overcome the inequality experience by Aboriginal and Torres Strait Islander people and achieve life outcomes equal to all Australians.” Sounds great, I know, but a key focus of the report was to increase the Aboriginal and Torres Strait Islander GP workforce through strengthening training opportunities and engaging and collaborating with students, training organizations and medical organizations. How effective do you think this is going to be as a strategy to improve health equity?

Karl Briscoe (28:26):

Yeah. Thank you, Charlotte. So I’d like to clarify that there is a current focus on increasing the representation of Aboriginal and Torres Strait Islander people working across all health disciplines of the healthcare system, not just increasing the number of Aboriginal and Torres Strait Islander GPs. Evidence clearly shows that our Aboriginal and Torres Strait Islander health workforce delivers better health outcomes for Aboriginal and Torres Strait Islander people. Although Aboriginal and Torres Strait Islander people are employed in the health and social assistance sectors more than any other industry, they are still very much underrepresented. Data from the 2016 census showed that Aboriginal and Torres Strait Islander people only represented 1.8% of the health workforce, despite being 3.3% of the Australian population.

Karl Briscoe (29:33):

It’s also important to understand Aboriginal and Torres Strait Islander people working in health, and more often in lower paid and less recognized positions, Aboriginal and Torres Strait Islander people must have equal representation in all roles, levels and locations across Australia’s healthcare system, education and training sectors to have a true ownership and autonomy of health and social and emotional wellbeing. To ensure coordinated and cohesive approaches to addressing the issue, since 2018 Aboriginal and Torres Strait Islander health leaders have been working in partnership with government to develop a 10-year national Aboriginal and Torres Strait Islander health workforce, strategic framework and implementation plan. And this is due to be released over the next coming weeks.

Karl Briscoe (30:38):

The plan sets an ambitious target and aims for Aboriginal and Torres Strait Islander people to represent 3.4% of the national health workforce by 2031. The focus on pathways for Aboriginal and Torres Strait Islander people to enter into training, education and the health workforce will be critical to achieving this target. With the 10-year life expectancy gap, being driven in part by lack of access to culturally safe and responsive care, Aboriginal and Torres Strait Islander people cannot afford to wait another decade for change, or for this plan to be ineffective. Everyone in this country deserves health equity. And I urge all of you listening today, to stand up and support our leadership on this issue. Do what you can to find out more about the plan, how you can assist. Together we will make a better healthcare system for everyone. The unique skill sets, the lived experiences and cultural insights Aboriginal and Torres Strait Islander people bring to the healthcare roles will strengthen the delivery of healthcare, both now and into the future for everybody. Thanks, Charlotte.

Dr Charlotte Middleton (32:09):

Thank you, Karl. That’s great. Thanks. I’m going to open this to all of you. We know that healthcare practitioners face considerable challenges in addressing this large scope of this crisis. We’ve covered off, there are so many points that add up to this health inequity. And many of the factors that make health more equitable, seem out of our control, obviously Medicare rebates being one of them. What do we think are small changes that GPS or other health practitioners or other people working in the health community on the ground could do to improve health equity in our communities?

Stephen Duckett (32:45):

What I think is interesting is, over the last couple of years, there’ve been a number of tools developed for GPs and other health practitioners to do social determinants, assessments of the patient sitting in front of them, that is a standardized way of asking questions. But in a sense, it’s a jogger for the GP to think, have I assumed that this person is in stable housing? Have I assumed that this person is able to eat nutritious food, for whatever reason? And so start to think about what, as part of the treatment plan for this individual, should I be doing?

Stephen Duckett (33:32):

Now of course, I’m not saying this is the only thing that GPs should do, but what I’m saying is, that is something that every GP can do. The second thing I’d say is that GPs, in their associations, such as in the college of GPs, can highlight these issues of equity, can highlight these issues of where our health provision is going wrong, to say, we do need to make sure everybody can get access to these services, and to address the issues of co-payments, to address the issues of people not getting adequate care.

Stephen Duckett (34:06):

And I think if we pursue a strategy at both the individual level and the organizational level, we’ve got a better chance of dealing with this issue.

Dr Charlotte Middleton (34:15):

Agreed. Carla. Oh, Carla?

Professor Carla Treloar (34:17):

Yeah. I totally agree with Stephen’s comments there, and particularly the individual and structural focus of action. I think it’s also important to roll in here the notion of trust. Those conversations to ask people, can you afford the prescriptions I’m writing, or fresh food, or do you have a place to exercise?

Professor Carla Treloar (34:41):

Those conversations need to have that element of trust between the practitioner and the patient, or the person in front of them. And trust is something that’s absolutely effective to good care, but it’s an ongoing project to win it. And things that have happened to a person, particularly living in marginalized circumstances, things that have happened before they walk through anybody’s door, will really affect how someone’s kind of sussing out the person, the GP or health worker in front of them. And that can be related to all sorts of things that are unrelated to the GP there, but absolutely very important to the person or the patient. So knowing that that relationship of trust has to be built and continually built, to be able to move into those conversations about, what are your social circumstances like? What’s your family circumstances like? What’s your income? How can I support you in making this? So it’s not a strategy that might work for everybody all the time or first time, but it’s absolutely, that trust is a good part of the work that’s needed to be done, particularly for people living in marginalized circumstances.

Dr Charlotte Middleton (35:58):

Karl, I’d love to hear your voice on this too.

Karl Briscoe (36:02):

Yeah. So from my perspective, sometimes it’s actually the small changes that make the largest difference. I’ve just discussed about the delivery of culturally safe and responsive healthcare, you get better outcomes for Aboriginal and Torres Strait Islander people. So implementing more culturally appropriate models of care is everyone’s responsibility. And in this regard, professionals at all levels can take time to think about and better understand the role they play in supporting culturally safe environments. It’s important that everybody working in the healthcare system reflects on their attitudes, stereotypes, and unconscious bias they bring to the table and how these will impact the healthcare that they are providing to others. Cultural safety extends beyond the provision of care and also needs to be thought of in a more holistic way. For instance, consideration needs to be directed to ensure workplaces are culturally safe and free of racism, and that structural inequalities, evident across the healthcare system, are addressed.

Dr Charlotte Middleton (37:23):

Yeah, fantastic points there, Karl. In fact, fantastic points all round. I guess, as a GP myself, I’d like to advocate for my fellow GPs that I couldn’t agree more with your comments, but all of this involves often, longer consults, more training and more resources. And as GPs, unless we get that support at a higher level, it is going to be very difficult for us to do more, I feel, than we are already doing. I’m sure it comes as no surprise to anyone that GPs are feeling particularly frazzled at the moment. We’re feeling very burnt out and we’re losing good doctors because of it. And a big part of this is the lack of increase in Medicare rebates that support us doing these longer consults, where we would be able to look into social determinants of disease and ask the pertinent questions, perhaps discuss cultural appropriate behavior in terms of how we approach our consults.

Dr Charlotte Middleton (38:36):

And so as doctors, a lot of us, we want to be able to do those things. We want to have that training. We want to be able to have those conversations with our patients, but we’re not being supported at a higher level. So it’s difficult times at the moment.

Stephen Duckett (38:56):

Sorry, Charlotte. I think I agree partly with you and I disagree partly with you. The first thing I’d say is, I think basically we under reward general practice in this country, that is, we should be putting more money into general practice. And we over reward specialist practice, in particular procedural practice. And so until we grasp the mettle of the incredible inequity within the medical profession about, some people can earn millions of dollars and general practitioners can’t, I think we’ve got a problem.

Stephen Duckett (39:29):

The second point I’d say is, one of the things that’s been talked about in this forthcoming 10-year plan, is a voluntary patient enrollment. And I think we’ve got to be thinking about how we can use that as a way of putting additional money into general practice, to reward continuity of care, and to reward general practitioners for dealing with, and treating and managing, the most disadvantaged in our society. And so they have time to spend the extra time that you rightly talked about.

Dr Charlotte Middleton (40:01):

Mm.

Stephen Duckett (40:01):

They’ve got the money to employ a practice nurse who can ring out and say, look, we haven’t seen you for a while. And we’ve actually checked on the computer system, you don’t seem to be taking your meds, or whatever it is. And so be much more proactive. So we’ve got to actually have a totally different thought process about what we’re doing with general practice and the medical profession as a whole.

Professor Carla Treloar (40:27):

And I think that’s where some different views of data can help. The ways in which we are under investing in some areas like general practice, and the costs of that, downstream or upstream, in relation to attendance at hospitals that could have been prevented and attendance at hospitals being much more expensive than being dealt with in primary care. So looking across what data is available to us, or building new ways to do that analysis, to make that very economic rationalist argument of, why we’re investing down the track when we could have done some prevention investments earlier in the person’s care career, to avoid more costly interactions later?

Dr Charlotte Middleton (41:13):

Yeah, absolutely. Dheepa, did you want to weigh in there?

Dheepa Jeyapalan (41:21):

I think my thing might be adding more to your plate, unfortunately, Charlotte. So I think that doctors, in their role and their whole authority in many areas, especially in regional areas, so being advocates for things that will have widespread impact. So advocating for better planning in local government areas so that there’s small green spaces and less high density amounts of fast food around. I think GPs just have an inherent role in advocating for that change, but I can understand what you’re saying, that there’s already so much, so having the ability to go out there and do that extra work, that support needs to come from the top as well.

Dr Charlotte Middleton (42:04):

Karl, did you want to say something more there, or …?

Stephen Duckett (42:08):

Yeah. I was just going to just say, just go on from what Carla was saying. Prevention is better than cure, so investing in the primary healthcare system, rather than the acute end, the downstream, you’re going to get much more. Yes, it’s quite longitudinal, the outcomes, but invest. If we start now, and in years to come, we won’t have to spend the amount that we do in the hospital system around treating illnesses that are totally preventable.

Dr Charlotte Middleton (42:50):

Well, like I said, it’s an area I’m passionate about as well. I absolutely couldn’t agree more. And looking at our last question, let’s have some positives perhaps, in terms of, how do we think health equity has actually improved over the last 10 years? And how can we build on this success? Stephen, I might start with you.

Speaker 5 (43:11):

If I go back more than the last decade, if I go back to the sixties, we didn’t have Universal Health insurance. We had really poor access in rural remote Australia. So what we are talking about now is a fundamentally different world from what it was back then. Over the last decade, we have seen some improvements. There are more doctors being graduated. There’re not as many of them going into rural and remote Australia as probably ought. And so we’re getting better geographic access. There’s been a massive expansion of Aboriginal-controlled community health organizations over the last 20 years. And that’s significant precursors, probably Karl will talk better about than me, about improving care that’s provided, culturally appropriate care to Aboriginal and Torres Strait Islanders. And so we are putting a number of these issues on the agenda, and I think that’s part of the issue. We recognize the problem, we are talking about the problem. We are making progress, not as fast as I would’ve liked, but things are better than they were.

Dr Charlotte Middleton (44:24):

You mentioned Karl. Karl, I might get your view on this.

Stephen Duckett (44:27):

Yeah, thank you. And thanks, Stephen. Although there is considerable inequity that still exists for Aboriginal and Torres Strait Islander people, there have been a number of positive developments over the past decade. From my perspective, and Stephen’s touched on this, the greater, there’s been greater recognition of the strength of community control, the need to work in partnership, to share decisions and to trust indigenous leadership. When we look at the community control health organizations, their boards are made up by Aboriginal and Torres Strait Islander people who are making decisions on their data that’s coming through the clinic, on what needs to actually be addressed. In terms of increased understanding of the critical role that culture plays in the health and wellbeing, and as well as the broad recognition of the existence and impacts of racism, and growing focus on cultural safety across the health system.

Stephen Duckett (45:40):

In this regard, APRA, they have a cultural safety strategy that has been increasingly a positive development. To build on the success, I’d like to see considered, coordinated and comprehensive investment and action on the full priority areas that are identified in the national agreement on closing the gap. These areas are a greater focus on shared decision making at all levels, strengthening and growing the community control, health sector, which Stephen has touched on, and eliminating racism and ensuring all healthcare and service delivery is culturally safe. And the last one, the priority area number four, ensuring equitable access to and the use of data and information, especially at the localized level, that will assist in addressing the health needs within that particular community.

Dr Charlotte Middleton (46:47):

Fantastic, Karl. Thank you so much. Dheepa, did you want to add to that?

Dheepa Jeyapalan (46:52):

I’d like to think about even just the last two years. We saw, during a difficult time, we saw policy action that public health advocates have been demanding for so long. And we saw the impact of them with the introduction of Jobseeker, JobKeeper, with free childcare and with temporary, accommodation being provided to people experiencing homelessness. These are policy actions that public health community have been asking for, for so long. And we saw them come to fruition. But now it’s about, how do we keep those things going? Because those are the policy actions that will have long and sustainable impact on the communities across Australia.

Dr Charlotte Middleton (47:32):

I’ll add Telehealth to that too. We’ve been advocating for that for a very long time, so to have that come in overnight was fantastic. And to stay, hopefully to stay. Carla, did you want to add to that?

Professor Carla Treloar (47:42):

Yeah. To echo that focus on the last two years. Although COVID highlighted many deep inequities across our communities, it also showed the way of how things can be done differently, including in social policy.

Professor Carla Treloar (48:02):

So those coronavirus supplements that were paid to people who were previously on NEWSTART and those who lost their jobs, dropped the rate of poverty across the country in ways that hadn’t been done for decades. And very importantly, dropped the rate of poverty among children in sole parent families, which are, it’s just a very high risk group from poverty, so halved the poverty rate for children, from 39 to 17%, because of those supplements. The impact of poverty on children is across their life course. So those choices that were made, for a short period of time, of increasing people’s supports, were great for that short period of time. It is a choice that we could continue to make as a society, to invest in very vulnerable people, that will lift their circumstances and particularly their impact on their health, and for children over their life course.

Professor Carla Treloar (49:02):

These things are choices, policy choices. They can be undone and done, as we’ve just seen in the last two years. And it’s really an opportunity to think carefully about what we want our society to look like in the next decade, or two decades or three decades, knowing that choices we make now will have those long-term impacts.

Dr Charlotte Middleton (49:24):

Fantastic. Thanks, Carla. I did not know those statistics. That’s amazing, that it halved.

Professor Carla Treloar (49:29):

Yeah. We’ll have a report coming out before the end of the year on that, so that’s hot off the press.

Dr Charlotte Middleton (49:34):

Fantastic. Thank you. Well, look on that note and on that positive note, I just wanted to thank you so much to all of you for being a part of today’s panel. Talking about something that obviously needs to be talked about, will continue to be talked about, and much needs to be done, but really fantastic to get all your views. Thank you so much for your time today.

Karl Briscoe (49:59):

Charlotte.

Professor Carla Treloar (49:59):

Thank you.

Dheepa Jeyapalan (50:00):

Thanks.

Stephen Duckett (50:00):

Thank you, Charlotte.

Dr Charlotte Middleton (50:00):

Thanks.