The evaluation found that the CHCI was not an appropriate response to the health and wellbeing needs of remote Aboriginal communities in 2007. These needs were, and continue to be, high and the existing health service was not adequate to meet these needs. The lack of participation by Aboriginal communities and the existing NT service providers and health professionals in the planning and delivery of the CHCI was not appropriate. The evaluation found that there was insufficient focus on identifying and specifically targeting existing gaps in health service delivery, that the significant gap was between primary care and referred services rather than in access to PHC, and that greater attention was needed on improving the patient journey through the system.
There does not appear to be a single, clear answer as to whether (and, if so, how) the CHCI created a bottleneck at the primary care and referred services interface, or whether there was an existing bottleneck—particularly if service providers already knew about the significant needs of the Aboriginal child population and a significant proportion of this population was already accessing PHC services. We suggest that the answer probably lies in a combination of the following points:
- before the CHCI, service providers knew about many of the children with the most serious needs and these children were accessing PHC and follow-up services; however, knowledge about the high needs of other Aboriginal children was at a population level, rather than knowledge of individual cases, so not all these children were accessing services
- before the CHCI many service providers were experienced in dealing with some follow-up needs themselves without having to refer to follow-up services
- before the CHCI, service providers may have considered referrals inappropriate because these services would not lead to a sustained benefit for an individual child if the child was going back to the same environmental conditions (such as overcrowded housing). Rather than taking a purely clinical perspective they were taking account of a broader population health perspective resulting in only the most serious cases being referred
- before the CHCI, service providers may have been discouraged from referring children because they were unlikely to be seen in time to benefit from the service, again resulting in only the most serious cases being referred
- some existing service providers and local health service staff may have become desensitised to the health needs of Aboriginal children and only referred the most serious cases
- the system was not coping with the existing number of referrals and so the bulge in referrals from the CHCI made the bottleneck to referred services more visible and severe
- it would appear likely that there were some over-referrals from the visiting child health check teams, probably due to several reasons. These may have included the inexperience of some doctors in remote Aboriginal child health and an inability of doctors to complete some follow-ups themselves because of the short time they were in the community. Together these may have led to doctors taking a precautionary approach to assessments and referrals.
The CHCI and associated data collections made the gaps in service delivery between primary care, secondary care and some other referred services more visible. However, the same cannot be said for other potential services addressing child health. For example, the CHCI and associated data collections did not effectively ascertain the level of need for a wide range of PHC services such as parenting support, health promotion, mental health services and alcohol and other drugs services. Nor did it effectively ascertain the need for social services including family, community and housing services. The CHCI data shows that out of 9,373 children just 43 were referred to mental health services, 53 to FACS and housing services and 65 to a social worker (Table 19). We assume that this significantly underestimates the need for these services. The CHCI model was, therefore, inappropriate for ascertaining the need for these broader services. The content of the health check was certainly comprehensive; however, the way it was delivered-often by visiting doctors and nurses who were not familiar with the children, their carers or their communities-contributed to a clinical and medical focus for the screening program (notwithstanding the efforts of many visiting teams and resident staff to encourage a more holistic approach).
The EHSDI’s focus on core PHC services and building relationships with Aboriginal communities appears to be appropriate. The components of the EHSDI are part of a long-term ongoing reform process which builds on previous initiatives within the NT health system. This has facilitated the development of a context-specific approach to PHC reform, informed by past learnings and premised on engagement with local processes. In addition, the decision to decentralise the planning and governance of the EHSDI to the NT fits with the aim of building a remote PHC system appropriate to the NT context.
Regionalisation, with its focus on Aboriginal community control and participation, has a sound rationale and is an appropriate way to plan and deliver health services in these parts of Australia. As discussed earlier, the partner agencies need to speak with a consistent voice about the aims of regionalisation, and work is required on the component parts of regionalisation to fully implement the policy and the change management process.
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