Dr Rob Roseby
The submission expresses the views of the following six paediatricians:
Drs Rob Roseby
Rose Fahy
Tors Clothier
Clare MacVicar
Alina Iser
Debbie Fearon
Contact author:
Dr Rob Roseby, FRACP
Respiratory and General Paediatrician
Senior Lecturer, Flinders University NT Clinical School
Head, Department of Paediatrics
Alice Springs Hospital
Postal address: Department of Paediatrics, Alice Springs Hospital, PO Box 2234, Alice Springs, NT 0871
This submission represents the views of the authors, who are the six consultant paediatricians in Central Australia. This submission does not necessarily represent the views of our employer, the NT Department of Health and Families.
This submission comes from the 6 paediatricians working in Alice Springs, comprising 5 who are predominantly hospital-based and one community-based, with a combined experience in child health in the Northern Territory of approximately 40 years.
We confine our comments to the child health check component of the Northern Territory Emergency Response, and the evidence on which we base our comments comes from the Central Australian catchment region. Almost all referrals for other services arising from the child health checks have been coordinated by our paediatric liaison nurses. The exceptions to this are referrals from the child health checks performed at Central Australian Aboriginal Congress in Alice Springs.
Our premise is that there is indeed an emergency or crisis in Aboriginal child health. Health data, on any measure of morbidity and mortality one can examine, educational outcome data, etc over decades all point to the fact that "something needs to be done". We would like to believe that the NTER was a well-intentioned attempt to be that something. However, its' two fatal flaws have been a lack of consultation and a lack of stated objectives. The lack of consultation resulted in a missed opportunity to more precisely target the intervention to achieve real benefits. The lack of stated objectives has resulted in the chaotic program rolled out in June, 2007 and makes a submission for this review somewhat difficult to focus.
Because of a relative lack of doctors in the NT, we calculate that there has been underinvestment through Medicare and the PBS in Aboriginal health in our region by tens of millions of dollars per annum. In the light of the magnitude of the problem and the quantum of underinvestment, we welcome the flow of resources into Aboriginal child health in the NT. We believe the resources have not been well spent, however. We make some proposals at the end of this submission for a way forward.
What is working?
While the NTER is not all good, it is not all bad either.
- As a result of the NTER there are some children who probably received health services which they would not have received otherwise. These may be primary care or specialist services.
- The publicity around the NTER has shined a light on a dark corner of Australia, being the plight of some Aboriginal children in the NT. It is hard to see policy-makers ever being able to ignore or accept the status quo anymore.
- The child health check program has exposed a number of doctors, nurses and other professionals to Aboriginal child health in the NT. We hope they have taken away a message for themselves and others that there is a great ongoing need for their expertise in this region.
What isn't working?
- It is difficult to know what can be achieved for a community by a program of child health checks. There is indeed published evidence in the peer review literature against such an approach.
- It is unclear how useful a one-off visit to a doctor can be for an individual child
- Supposing child health checks were useful as a screening exercise for
epidemiological purposes (which they are not, but let's suppose they
are for this exercise). As for any screening test, an epidemiologist would
first attempt to standardise the screening tool, such that every test was
carried out in a similar manner, with similar interpretation of information.
This was missing from the NTER child health checks. While the visitors performing
the checks were all well-intentioned, they had a great variety of differing
clinical experience and understanding of Aboriginal people. Some of the
visiting doctors were even adult-specialists. We believe there were an adult
haematologist and an adult surgeon, and possibly others without experience
with children among the doctors performing the checks. Would you take your
child for an opinion from such a doctor? (The answer to that should be no!)
Why then is it acceptable for the Australian Government to provide such
a doctor to give opinions about Aboriginal children? This is not to malign
these specialists who were answering the call to help in the emergency,
but it highlights the difficulty of the approach to the health checks.
- There was inadequate clinical orientation- even for those who are familiar with child health, the range of clinical problems in Central Australia is vastly different from common problems encountered elsewhere.
- There was inadequate cultural orientation
- The above problems account for the variability in referrals coming from the different communities, and the quality of those referrals.
- Of a randomly selected sample of 50 consecutive echocardiograms (an ultrasound of the heart performed to look for structural abnormalities) referred by the NTER child health checks, 49 were normal, with the abnormal result subsequently found to be clinically trivial. A number of these tests were duplicate investigations. A more comprehensive examination of these expensive investigations is possible, if the review committee would like this performed.
- We have examined a sample of 25 referrals to paediatricians from 4 communities. Of the 25, almost all were already known to the paediatrician so the referral was duplicating an extant service. There was one child known to be at risk of sexual abuse, an aspect missed by the NTER health check. Few of the referrals were thought to be useful overall, with most of the new issues brought to attention by the health check teams considered to be firmly in the primary care, not specialists', domain.
How is each NTER measure performing and how should each be taken forward?
- We have no basis on which to make comment on performance overall.
- With respect to ear health, we have heard publicity surrounding the increased number of ear operations performed as a result of the NTER. We feel it is crucial to rigorously evaluate outcomes for the children involved, recognising the low success rates for tympanoplasty operations even in the best of conditions, with close follow up.
What progress has there been in improving the safety and well–being of Indigenous children?
- Some Aboriginal people from different communities have told us that the increased police presence is welcomed.
Will the suite of measures deliver the intended results?
- What are the intended results? We have not heard any objectives articulated.
Have there been any unintended consequences?
- The morale of those committed to working in this region for a significant period of time has been adversely affected.
- By offering higher rates of pay, the NTER has poached some of our staff to achieve its short term goals.
- The NTER has used up significant goodwill from those doctors who might have come to the NT for a period longer than just the 3 weeks, but have now had their NT/ Aboriginal health experience.
- The NTER has certainly distracted us from our daily work at times. For example, all of the children referred to us and subsequently seen (as described above) take the place in the clinic of someone else. In general, the referrals from elsewhere, for example GPs or DMOs, are of a much higher quality than those from the NTER child health checks.
- The NTER risks being confused on communities with existing health services. Through no fault of theirs, by being culturally insensitive or offensive, visiting doctors and nurses risk decreasing the likelihood of a carer taking a child to seek help subsequently. This is a phenomenon recognised in the literature, and is the reason why "ethics in human research committee" applications specifically ask researchers about this issue.
Will NTER lay the basis for a sustainable and better future for residents of remote communities and town camps in the NT?
- There is nothing sustainable about the child health check component of the NTER
- We hold out hope that other components of the NTER were better thought through than the child health check component.
What alternative measures should be considered?
- Invest in sustainable primary health care
- Invest in preventative dentistry.
- Consult with specialist colleges to investigate how to better encourage specialists and trainees to work in this area, especially general practitioners, ENT surgeons and paediatricians. Community paediatricians are among those with expertise to devise programs to target the determinants of child health.
- Provide a weighting through the MBS for specialists to see Aboriginal people- children and adults.
- We wish to emphasise that poor health is an outcome of a raft of social factors which include housing quality, overcrowding, hygiene, nutrition, education, etc and that long term solutions to health inequalities lie in these fields as well as in the health sector.
Are there other ways of working that would better address the circumstances facing remote communities and town camps?
- It is not too late to take a more rational approach to child health and
wellbeing in Central Australia.
- Consult with Aboriginal people
- Consult with experts in Aboriginal child health
- Consult with existing services, so as to work in harmony with them
- Identify and articulate objectives, priorities and possible solutions
- Implement strategies based on priorities and objectives
- Review performance against the priorities and objectives including a cost/ benefit analysis.
We would be happy to provide clarification or further information regarding this submission. Thank you for the opportunity to make comment.
Yours sincerely,
Submitted by email and therefore unsigned August 15, 2008
Dr Rob Roseby
Dr Rose Fahy
Dr Tors Clothier
Dr Clare MacVicar
Dr Debbie Fearon
Dr Alina Iser