Introducing the Core Services and Outcomes Framework

What community-controlled comprehensive primary health care offers and why it matters for advancing health and wellbeing of Aboriginal and Torres Strait Islander peoples.

In Australia, Aboriginal and Torres Strait Islander Community-Controlled Health Services were the first to offer comprehensive primary health care and are acknowledged in multiple forums as the best example of community-based health infrastructure improving health and wellbeing.

History

In 2019, the Board of the National Aboriginal Community Controlled Health Organisation (NACCHO) and the sector more broadly acknowledged the importance of describing the principles, scope and functions of comprehensive primary health care when controlled by Aboriginal and Torres Strait Islander communities. National consultations and extensive feedback produced the sector’s Core Services and Outcomes Framework. The NACCHO Board will use the Core Services and Outcomes Framework to advocate for the funds the sector requires to deliver better health and wellbeing for Aboriginal and Torres Strait Islander peoples. This brief overview is an introduction to the key elements of the Core Services and Outcomes Framework. More information is readily available in the complete document.

Impact

Aboriginal community-controlled comprehensive primary health care is highly cost-effective. The transition of one remote health clinic from government management to Aboriginal community controlled comprehensive primary health care increased utilisation of primary health care by 408 per cent; accelerated immunisation rates; reduced the proportion of babies born with low birth weights to less than 10 per cent; and increased employment opportunities for local Aboriginal and Torres Strait Islander people. Prevention, early intervention and chronic disease management are tailor-made to each person with community-wide health promotion and knowledge sharing to support community empowerment. One major study concluded that: ‘… up to fifty percent more health gain or benefit can be achieved if health programs are delivered to the Aboriginal population via ACCHSs, compared to if the same programs are delivered via mainstream primary care services’. More information is readily available in the complete document.

To call yourself a comprehensive primary health care service, you need to be more than a ‘sick care service’. You also need to be public health advocates to garner action on poverty and overcrowding.

You must invest in communities, develop leaders and reclaim community empowerment. You must look to act on social determinants of health as well.

Participant at CSOF Expert Advisory Group meeting,
Sydney, December 2019

Framework Principles

Aboriginal and Torres Strait Islander leadership and control are not negotiable as a foundation for primary health care service design, integrated client/ family-centred care and community empowerment that will achieve better health and wellbeing

Social, cultural, historical and economic determinants of health matter

Comprehensive primary health care as an accessible and generalist ‘front-line’ service based on relationships is the cornerstone of a sustainable health-care system

A model of community-controlled comprehensive primary health care will support consistently high standards, ensure sustainability for primary health care services controlled as an act of self-determination by Aboriginal and Torres Strait Islander peoples and achieve health equity

Operating Principles

Governance guarantees service quality and impact
Service delivery models of care are set by the board
Infrastructure enables and supports
Social determinants of health may not always be within the direct sphere of control of ACCHSs but will always be within their sphere of interest and concern
Service delivery models of care promote and safeguard integrated, person-centred care
Service delivery models of care will be evidence-based and increasingly welcome knowledge and evidence produced by Aboriginal and Torres Strait Islander scholars in partnership with Aboriginal and Torres Strait Islander communities and services
Aboriginal and Torres Strait Islander staff will flourish in ACCHSs as work environments placing high value on their skill sets, their connections within communities and their knowledge of culture

This is an outstanding piece of work, thoroughly comprehensive, and with reference to all the key elements, funding, workforce, training and, importantly, CQI.

It is, in my view, international best practice and of textbook quality. I know of nothing that is remotely comparable for mainstream health services in Australia.

Professor Ian Ring, AO

How the 'model' works

This visualisation has been developed to convey the components of the Model of community-controlled comprehensive primary health care that is the foundation for this Core Services and Outcomes Framework.

People

Aboriginal and Torres Strait Islander people surround all components of the Core Services Outcomes Framework. People benefit from Aboriginal and Torres Strait Islander community controlled comprehensive primary health care as health infrastructure. Every ACCHS is controlled by the community receiving the service.

‘Indigenous peoples have the right to determine and develop priorities and strategies for exercising their right to development. In particular, indigenous peoples have the right to be actively involved in developing and determining health, housing and other economic and social programs affecting them and, as far as possible, to administer such programs through their own institutions’.

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Culture

Culture is the first rim of the Core Services and Outcomes Framework because culture keeps communities strong and healthy. Culture is highly correlated with empowerment, health outcomes and other positive social impacts such as employment and education.

Culture is central to a holistic understanding of health and wellbeing, and shapes relationships across self, country, kin, community and spirituality. Cultural determinants of health are anchored in Aboriginal and Torres Strait Islander ways of knowing, being and doing.

As the health system becomes more complex, the role of community controlled primary health care as an act of self- determination becomes even more critical.

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Community control

‘Community control’ is not just a term—it is a 48-year-old model forged at Redfern in 1971— and now exercised in 144 local Aboriginal and Torres Strait Islander communities across the country.

Community control accelerates the attainment of health and wellbeing for Aboriginal and Torres Strait Islander peoples in two ways: firstly, the assignment of authority to select, design, manage and be accountable for community- based health care increases health impact, and secondly, the lived experience of genuine individual and community empowerment leads to more equitable power relations in Australian society.

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Aboriginal And Torres Strait Islander leadership

‘Health done our way is unique’

Aboriginal and Torres Strait Islander leadership, past, present and emerging, is visible at every level and in every activity of an Aboriginal and Torres Strait Islander community-controlled organisation. Young people’s leadership is also developed.

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Cultural authority

Cultural authority is asserted through sound governance, community-elected boards, meaningful community consultation and constant recalibration of any aspect of service design and delivery that might push up against culture. Each ACCHS reflects its local community’s strengths, priorities and solutions. One example is kanyini, a Pitjantjatjara word conveying the principle of connectedness through caring and responsibility. These connections ‘hold’ a community together, build resilience and the deep strength essential for a vibrant society and healthy people.

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Needs Assessment

Under Development

Outcomes

Under Development

Governance

Exercise of community control and cultural authority occurs through governance structures that meet explicit criteria. To be classified as an Aboriginal and Torres Strait Islander community- controlled organization, an ACCHS must have a registered membership base which elects its board. Each ACCHS constitution specifies membership criteria, admission to membership and eligibility to vote for board directors. This board sets strategy, and oversees management and operations in delivering against the strategy. Quality and safety are the responsibility of the board, bringing primary accountability for health outcomes back to the community.

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Clinical services

ACCHSs ensure their own services are culturally appropriate, physically accessible, financially affordable and provide the necessary supports with language and health literacy. Clinical services cover diagnosis, investigation and evidence-based treatment of illnesses, injuries and diseases affecting people and inhibiting their quality of life whether acute, short-term, long-term or lifelong. In Aboriginal and Torres Strait islander community-controlled comprehensive primary health care, clinical services are holistic in approach to include all body systems including mental health, cardiovascular, renal, respiratory and others. Comprehensive primary health care must deliver clinical services that are evidence-based. This care must be person-centred. This must be more than various members of the clinical team simply accessing a shared electronic clinical record. Strategies must be in place to integrate visiting service providers,contracted clinicians and staff in a common service model, focused on the client, their lifecourse and family. The capacity of an individual or family to self-navigate a Western health system or self-care must be assessed and the appropriate supports put in place. This complexity of clinical presentations and treatment pathways (the client journey) may require novel service models and innovation to ensure clinical outcomes are achieved efficiently, effectively and equitably in a culturally safe way. Aboriginal and Torres Strait Islander peoples are disproportionately more likely to be experiencing trauma. ‘Bush medicine’ and traditional healers have always held a central place in Aboriginal and Torres Strait Islander healing systems and are now being recognised by governments and Western health systems.

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Policy direction and partnerships

As experts in Aboriginal and Torres Strait Islander health and wellbeing, ACCHSs willingly share their much-needed knowledge and insight with others. ACCHSs persuasively influence the work of others, as an equal partner in co- design and shared decision-making. This includes effective engagement to lead policy and its implementation. In conjunction with their respective state or territory affiliate, this domain ensures ACCHSs can effectively advocate and influence legislation and other critical aspects of health system design aligned to the Priority Reforms of the National Agreement on Closing the Gap such as contracting and commissioning, research and evaluation, data sovereignty and shared decision-making.

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Community health promotion and empowerment

Supporting the creation and maintenance of physical, social and cultural conditions that promote health has always been at the heart of community controlled comprehensive primary health care. This includes identification of health threats and mobilising action to address these threats through leadership and collaboration with other organisations. Effective health promotion reduces the burden of disease through primordial prevention (addressing the ‘causes of the causes’) and primary prevention (reducing risk factors before disease occurs). These are also known as ‘population health activities’. Population health activities and clinical service delivery are integrated to complement and amplify each other. Specific programs in Aboriginal and Torres Strait Islander health promotion have been effective in changing individual risk factors and disease progression. While social issues such as poverty, housing, education and food supply may not be within the direct control of primary health care, these factors are acknowledged through empowerment strategies that are culturally-based and community-led. Health promotion is prioritised, co-designed and experienced on the ground by the community.

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Artwork

The Core Services and Outcomes Framework artwork was created by Kamilaroi artist, Ethan French.

The diagram is a visual representation of the Core Services and Outcomes Framework foundations for community-controlled primary health care. At the centre of the diagram is a meeting place which represents members of the community being the heart of this document. Each ring and section of the diagram represents each component of the Core Services and Outcomes Framework, with culture surrounding the whole diagram and foundations, which is a representation showing that culture is involved in all aspects of the Core Services and Outcomes Framework.

... health done ‘our way’ is unique.
It is a holistic system grounded in truth, lived realities, our culture, law and country. ...You can bring these ingredients together, utilise changing structures and relationships to design the culturally informed health models and work programs our people need. It is the way that we deliver our work from the ground up that informs the best policy and legislation. We have to seize this moment.

June Oscar, speech at AMSANT conference, August 2019